MANUAL fe
OF
2% »
+
“ | Obstetrics, Gynecology and Pediatrics,
i
BY
KENNETH N. FENWICK, M.A., M.D.
Prof: Obstetrics and Diseases of Women and Children, Royal Colleye of
Physicians and Surgeons in affiliation with Queen’s University, oe
Kingston ; Member of the Royal College of Surgeons, England ; coca
Fellow of the Obstetrical Society, Edinburgh; and ote 2g
Surgeon to the Kingston General Hospital. ) . a
KINGSTON, ONTARIO :
JOHN HENDERSON & CO,,
1889,
Entered according to Act of the Parliament of Canada, in the year one thousand { ,
eight hundred and eighty-eight, by Kenner N, Fenwick, M.A., M.D., Kingston,
Ontario, in the Office of the Minister of Agriculture.
Jel i se ar Oe
The object of this little book is to furnish an outline of the
main facts in Obstetrics and the Diseases of Women and
Children, and includes a synopsis of the physical signs of
Diseases of the Chest and Diseases of the Skin.
1t is really a syllabus of my sessional lectures with such
®@ additions and alterations as I thought would make it more
| valuable for reference in emergencies.
thousand =|
Kingston, . 4 , ‘
While seeking to meet the wants of the medical student in
® general, and my own class in particular, the work does not
pretend to originality, nor does it aim at supplanting the
larger text books on the subject which are not always within
the reach of every medical student.
Elegance of expression has often been sacrificed to con-
iciseness, for obvious reasons.
In conclusion, I wish to acknowledge my indebtedness to
Mr. J. R. Shannon, B.A., for valuable assistance in revising
© proofs.
—
|@ 141 Kine Sr. W.,
KINGSTON.
146756
CONTENTS.
eee () omer
OBSTETRICS,
PAGE,
i 3A. THE FEMALE ORGANS OF GENERATION, - - - : - |
I. Hexternal
1. The pudenda,
Mons veneris, labia
Majora and minora,
Clitoris, vestibule, hymen - - - : 2
Curuncule myrtiformes, and
% Fossa navicularis
P| 2, The Vagina.
> =I. Internal. : : : : al ER rh Sea ao Ae ay 3G
1, The Uterus.
2. The fallopian tubes.. - : : : : : :
Graaffian follicle. : : : - - : - 6
Parovarium, ovum,
y IIL. Periodical Ovulation - + + - i oe 7
38 1. The discharge of the ovum.
On
2. Menstruation. : : : : - : - - 8
3. The Corpus luteum. - : : : : - : 10
4 False and true.
= si1V. *Fecundation of the Ovum. UATE COU cas se Re eg |
7 V. Development of the Ovum. - + += + © + 12
E 1. Formation of nucleus of vitellus, : : : - 13
: 2. Segmentation of vitellus.
3. Formation of the membranes, - - : : : 14
Amnion, allantois, chorion,
Umbilical Vesicle. - : : : - : - 15
4, Preparation of the Uterus to receive it. - - - 16
is Decidua vera, retlexa, and serotina.
a 4 5. Formation of the Placenta,
a the umbilical cord. - : : : - : - 18
vi. CONTENTS.
VI. Development of the Embryo. . . . -
1, Of its various parts. 4
2, As a whole. - - AGE . - - 20 @
B. PREGNANCY.
I. Changes occurring in the mother. - - - - - 22
1, In the sexual apparatus.
2. In the system at large. - - . - . - 23
Il. The signs of pregnancy. : - : : : 24
1, Cessation of the Menses,
2. Mammary sympathies
3. Abdominal enlargement. - - - - - 25
4, Ballottement. - . ; - . . ° - 26
5. Quickening.
6. Auscultation. is fe A's - oot le
(a). Pulsation of foetal heart.
(6). Uterine souffle.
7. Jacquemier’s Test, - - - - . - - 28
8. Intermittent Uterine Contractions.
9. Kyestine in the Urine.
10. Morning Sickness.
11. Salivation.
III. The Disorders of Pregnancy. - - . - - - 29
1. Local.
(a) (Edema of Labia. a
(b) Pruritus of Vulva. Pd
(c) Metritis.
2. Reflex.
(a) Neuralgia.
(6) Salivation.
(c) Vomiting.
(d) Constipation.
(e) Syncope. a C.
(f) Insomnia, s
3. Mechanical, abi - - . . . . 30
Hygiene of Pregnancy.
IV. Abnormal Pregnancy. - - - - - . - 30
1, Due to peculiar conditions of uteru:
(a) Double. (6) Displacements, a
2. Due to peculiar conditions of decidua. a
CONTEETS. vii.
19 a 3 3. Due to peculiar conditions of placenta. Reyes eB
4 As to form, position, development, and nutrition.
- 20 & 4, Due to peculiar conditions of amnion and its fluid.
be (a) Excess—hydramnion.
: (6) Deficient,
a8 5. Due to peculiar conditions of the cord,
93 6. Due to peculiar conditions of the chorion. Hydatidi-
form mole,
- V. Premature expulsion of the ovum. Abortion. <> 78. ae
Causes—
1, Maternal. (a) Predisposing. - - - - . 34
- 2 @& (b) Exciting.
- 8 & 2, Footal.
L Diagnosis, prognosis, - - - - «+ = « 35
> 27 : Treatment. - - - - - - - . 36
4 1. The prevention of habitual abortion,
2. The arrest of threatened abortion.
2 3, The management of inevitable abortion.
(a) Where the sac is not ~uptured.
(6) Where the sac is ruptured.
4, The management of neglected abortion - - 37
& 5. The management of premature labors.
- 29 a VI. Retrauterine pregnancy, or ectopic gestation. - . e 38
a 1, Tubal pregnancy.
2. Ovarian pregnancy,
3. Abdominal pregnancy.
: Symptoms, termination, diagnosis,
i? Treatment, ee CAVA Oh ht ee i i I,
eR 1. Cases of early gestation.
= 2, Cases of advanced gestation.
(a) Footus living.
(6) Fostus dead.
3 C. Lazor,
hee 4 I. Duration of pregnancy. Saas A AN a See emery
1 II. Cause of onset of labor.
- 30 a III, Symptoms, - : - - - - - : - 42
Ei Premonitory.
Ist stage. 2nd stage. - : - - - 43
Srd stage. - - - . . ge ae
Vill. CONTENTS.
IV. Duration of labor.
V. The eupellent forces. - ° ° . .
1. The uterine contractions.
The nervous mechanism of labour.
2. The accessory forces. -
VI. The mechanism of labour,
1, The female pelvis.
Its planes and axes. - - - . -
2. The fcetal head. : -
Its sutures, fontanelles, and icinabaue,
VII. Zutocia or normal labor.
The position of vertex,
Ist Position.
1. Descent and flexion. - - - . :
2, Rotation. : : : - : :
3. Extension.
4, Restitution.
5. Expulsion of the trunk.
2nd Position. - : : - . ; ; ‘
8rd Position,
1, May be converted into 2nd.
2, Persistent 3rd.
4th Position. : : - - - ‘ *
Management of labour, : . ° , ‘ é
Of Ist stage. . - . . - “7
Of 2nd stage. - - - - - . P
Of perineum. - - - - ‘ ;:
Of 3rd stage. - - - - ‘ A 4
Use of anesthetics.
VILI. Dystocia or extraordinary labor, - + = «© «
1, From imperfect uterine efforts.
(a) Irregular action.
(b) Inertia. : : : : :
Use of ergot—its indications and contra- tndiowitua
2. From impeded uterine efforts.
(a) Connected with the foetus.
(2) From abnormal position.
(i) Face presentation.
58
59
59
61
61
62
63
64
65
66
CONTENTS. ix,
(ii) Breech presentation. - : - 68
455 Management. A ae - 70
Treatment of aftercoming head.
- 46 (iii) Shoulder presentation. : : 71
48 Terminations and treatment. - - 72
(8) Size and form.
- 50 & . (i) Large heads.
§ (ii) Deformities.
51 (vy) Number.
- 53 Multiple pregnancy.
if 54 Twins. - : : : : : 73
(6) Connected with the passages.
55 (a) Pelvis, - - - - - - - 74
(i) Contracted pelvis proper.
56 Ist. Pelvis Aquabiliter Justo-minor.
_ 57 2nd. The flattened pelvis. - : 75
3rd. The flattened generally con- ;
tracted pelvis.
(ii) Irregular forms.
oi Ist. The Negele Oblique.
2nd, The Kyphotic.
- 8rd. The Scolio-Rachitic.
Measurement. - - - 76
- 59 I, Internal pelvimetry.
é 59 fo II, External pelvimetry.
gt Influence of contracted pelvis.
ge 1, During pregnancy. -~— - 77
. 62 2. During labor.
; 63 Treatment. - : - 78
ae (B) Os uteri.
4 (a0, an cr a at mE RR, {1
- 64 q (ii) Rigidity.
x (iii) Induration.
. & (y) Vagina.
- 65 a (i) Atresia.
66 g (ii) ‘Tumors.
a (c) Connected with the secundines. - - - 81
P| (a) Liquor amnii.
(i) Abundant,
(ii) Deficient.
1V. Craniotomy.
V. Embryotomy.
1, Exenteration. :
2. Decapitation.
VI, Caesarean Section,
K. Diseases oF CHILDBED,
I. Convalesence and its disorders.
CONTENTS,
(8) The membraes.
(y) The cord,
(i) Short.
(ii) Entangled.
(iii) Presenting.
(6) Placenta.
(i) Adhesion. -
lst. Simple retention.
2nd. Hour-glass contraction.
3rd. Morbid adhesion.
(ii) Preevia.
3. Complications of labor.
(a) Hemorrhage.
(a) Accidental,
(8) Unavoidable.
(y) Post partum.
Treatment..
Secondary uterine hemorrhage.
(b) Eclampsia or puerperal convulsions,
(ec) Syncope. -_. :
(d) Inversion of the uterus,
. (e) Rupture of the uterus,
D, OBsTETRIC OPERATIONS.
I. The induction of premature labor.
iI. The forceps.
III. Version or turning.
VII. Ovaro-hysterectomy.
VII. Laparo-Hlytrotomy,
81
CONTENTS. xi.
4
sl | i Dinesot Mae 2 oe re
12 1. Sore nipples.
4 2. Mastitis. - at - . , - ‘ - lll
4g 3. Defective secretion of milk, - - . . - 112
a 4. Galactorrhea. - - - - : : - - 113
3 III. Puerperal fever.
- 8 Treatment. a AR a ye coagigle g uy tS |
| IV. Puerperal venous thrombosis and embolism. - - - 120
eT 1. Pulmonary obstruction. Seaivapne : oc RR
- 83 é 2. Phlegmasia alba dolens. - - - . : - 122
. 86 ae V. Puerperal insanity. : - - . . oe), wo ot RBS
- 87 GYNAECOLOGY.
. 88 | Hg
- 90 Diagnosis. - : . - P - 128.
q A. Non-INSTRUMENTAL EXAMINATION. - - - : . - 130
/ : a. 1. Eeternal abdominal.
; 1. Inspection.
ic 4 2. Palpation. - ~- : fa Fee : : - 181
a 3. Percussion.
4, Auscultation.
: : oe II, Inspection of the external genitals.
- 101 4 Ill. Digital examination. : : 5 - : : - 132
* 1. Vaginal.
| 2. Rectal. Ce a ee ee
a 4 3. Vesical, ©
ae : IV. Bimanual.
- 104 |
) 3B. lnsTRUMENTAL EXAMINATION.
- 105 a I. The speculum.
' § iia fe Re ee
- 16 & 2. Bivalve.
- 107 4 8. Duckbill.
Il. The uterine sound.
Uses and contra-indications. - - - - 135
Other instruments.
xii, CONTENTS.
SPECIAL DISEASES.
A, DISASES OF THE VULVA, = + - += += = = - 137
I, Malformations. 3
II, Inflammation. a We RE TMC see My Rel 4
SII, New Growths, -
IV. Rupture of Perineum.
Causes,
1, Owing to the mother.
2. Owing to the child.
3. Owing to the physician. - - - - : - 139
Its nature and effects.
Treatment.
1, The immediate or primary operation. - - - 140°
2. The secondary operation.
(a) Partial rupture,
(b) Complete rupture,
B, DISEASES OF THE VAGINA. - . . : . shi a a ’
I, Malformations.
II. Vaginismus.
III. Inflammation. - - - : - - - - 142
IV. New Growths.
V. Fistule.
Vesico-vaginal fistula.
Causes,
1. Traumatic. : : : 5 - - - 143
2. Pathological.
Symptoms, operation.
C, DISEASES oF THE UTERUS,
I, Disorders of menstruation. ; 4 |
1, Amenorrhea, - : - - cae : - 144
(a) Delayed menstruation.
(2) From congenital malformation. §
8) Functional,
CONTENTS. xiii,
(b) Suppressed menstruation. - . : - 145
Causes, symptoms, treatme..t.
2, Dysmenorrhea.
- 137 4a (a) Neuralgic.
- (b) Congestive.
138 4 (c) Obstructive. - - = - + 146
. & (d) Membranous.
(e) Ovarian.
3, Menorrhagia. - : : : - : 147
Symptoms, pathology, treatment. - - - 148
Leucorrhea,
- 139 1. Vaginal,—(a) acute, (b) chronic.
2. Uterine. - - : . » 149
Sterility.
Causes. - : : : : - : - 150
“ Treatment. - : . : . - 15)
Il. Malformations.
III. Stenosis of 08 wteri.\- : - - . - - «+ We
a Iv aaa st - - 153
- M41 ss 1, Endometritis.
a (a) Acute, (b) chronic.
: Pathology, causes, symptoms, and treatment. - 154
142 2. Acute Metritis.
3, Chronic Metritis : - : : : : - 155
Subinvolution.
Symptoms and treatment. - . : - - 156
V. Dislocations or displacements. . . - + - 157
3 Causes. - : : © - : - - 158
Peta! - 1. Anteversion. - : é ; ' . , - 159
4 2, Anteflexion.
" Symptoms.
a 3. Retroversion. ps Me es a
a eee - 162
4 5. Prolapsus. - - . : ; - - : 163
144 : 6. Inversion. - : - - : - - - 165
VI. New Formations. Sao ee rE ee Ue ag }
— 1. Fibro-myoma. | :
2, Fibro-cystic. Stic aN de Baa ee :
3. Uterine polypi. - - : . - - - 170 |
xiv. CONTENTS.
4. Carcinoma.
Cancer of cervix.
do ofbody. - ,
VII. Laceration of the Cervia. - - -
‘D. DisEasEs or PELVIC CONNECTIVE TISSUE,
- I, Parametritis.
(I. Perimetritis. - - - - -
III. Pelvic hematocele.
E. DISEASES OF THE TUBES AND OVARIES. -
I. Of the tubes.
II. Of the ovaries,
1. Prolapse,
2. Odphoritis. -
3. Ovarian tumors. -
F. DrIskasEs OF THE BLADDER.
I. Malformations.
II. Cystitis,
III. Caleuli and foreign bodies. -
VI. Functional diseases.
1. Irritability,
2. Incontinence. — - - -
3. Retention.
4, Dysuria.
V. New growths.
VI. Diseases of the urethra.
1. Urethritis. : . ‘ *
2. Fissure.
3. Prolapse of mucous membrane.
4, Caruncle,
“G. NEUROSES. - : . . Z i
I. Hysteria,
Il, Hystero-epilepsy, - - - .-
III. Newrasthenia,
172
172
175
176
177
179
180
18]
184
185
186
187
187
190
CONTENTS. xv.
PEDIATRICS.
. 172
- 172 General examination of children, - 162
é 175 Treatment of the new born infant. - 197
Asphyxia. - : : - 198
Selection of wet-nurse. - : - 199
176 Hand-feeding,
; 177 I, Diseasis of Intestinal tract.
1, Dentition, - - : 201
- 179 2. Thrush, - - : - - - 202
3. Stomatitis. - - 203
(a) Aphthous.
(b) Ulcerative.
s 180 (c) Gangrenous. - 204
- 181 4, Marasmus.
5. Gastric catarrh. - - 205
184 6. Diarrhea, He vecan sony - 206
(a} Simple.
(b) Inflammatory. 207 .
(c) Choleraic. ;
- 185 7. Dysenteory. : - - - 208
8. Constipation.
9. Intestinal obstruction. 209
: 186 10. Intestinal worms,
. Diseases of the Nervous System.
| 1, General symptoms. : - 210
2. Convulsions. oie, Ma 211
- 3. Hydrocephalus. : : - - 212
4 4, Tubercular meningitis. ete 213
- lrg 5. Acute infantile spinal paralysis. : - 214
q 6. Pseudo-hypertrophic paralysis. - - - - 215
5 III. Diseases of the respiratory system. - . a “ - 216
1. Examination of the chest.
Physical signs.
187 2. Laryngismus Stridulus. - : - - - 222
3 3. Diphtheria. : : : - : : - - 223
- 190 (a) Pharyngeal.
(b) Laryngeal, —Croup.
CONTENTS.
4, Bronchitis, -
5. Pneumonia. -
(a) Croupous.
(b) Catarrhal.
6. Pleurisy. :
Empyema,
IV. Diathetic diseases.
1. Scrofula.
2. Infantile syphilis. -
V. Diseases of the liver.
i. Jaundice,
(a) Icterus neonatorum.
(a) Benign.
(8) Grave. -
(b) Icterus of childhood.
2. Amyloid liver.
3. Fatty liver. -
VI. Acute infectious diseases.
1. Mumps.
2. Measles.
3. Rétheln. -
4, Scarlet fever.
5. Varicella. -
6. Whoopingcough.
VII. Diseases of the skin.
4%
a
Mi *
Dae
Sea
OBSTETRICS,
" GGYNMCOLOGY AND PEDIATRICS.
—_o——-
OBSTETRICS.
A.—TuHe FemMALe OrGANS OF GENERATION.
L EXTHRNAL. |
1. The Pudenda include all those parts which are visible
externally, viz. :—Mons Veneris, labia majora, labia minora,
| clitoris, vestibule, hymen, caruncule myrtiformes, and fossa
> navicularis.
a. The Mons Veneris, or “ mount of love,” is an irregular tri-
P angular prominence, situated in front of the symphysis pubis.
® After puberty it is covered with a thick growth of coarse hair
and is sharply defined above by a line at the lower part of the
shypogastric region.
_ 6. The Labia Majora are two cutaneous folds beginning
at the lower part of the mons veneris, co.stituting the
Manterior commissure ; and extending downwards on each side of
the vulvar cleft, terminate by blending with the integument of
3 he perineum. Unless the thighs are abducted the inner sides
of the labia are always in contact.
ce. The Labia Minora, or nymphe, are two muco-cutaneous
@folds springing from the inner surfaces of the labia majora, and
have been compared to a cock’s comb. They begin just beloy,
the anterior commissure as double folds which meet above and
9 OBSTETRICS.
below the clitoris, forming the preprce and frenulum of the
clitoris ; and descending on each side of the vestibule and
on the inner side of the labium bond with its middle
part. They however unite again by a muco-cutaneous commis-
sure below known as the fourchette.
d. The Clitoris is a small curved oblong organ, analogous to
the penis in the male, situated just below the anterior commis-
sure. It appears as a small pear-shaped projection, the glans,
covered above by the prepuce, and attached by its body to a
point immediately under the anterior edge of the arch of the
pubis where it divides into two crura. It consists of cavernous
or erectile tissue, surrounded by a firm fibrous coat over which
is an extremely sensitive tissue.
e. The Vestibule is a triangular space bounded on each side
by the labia minora, below by the vaginal orifice, with its apex
immediately below the clitoris. In the median line of this
space, three quarters of an inch below the clitoris, is the meatus
urimareus or urethral orifice, which appears as a dimple or
pucker in the mucous membrane and serves as a guide in intro-
ducing the catheter.
J. The Hymen is a circular or crescentic fold of connective
tissue, covered by mucous membrane, which immediately sur-
rounds the orifice of the vagina,
g. The Caruncule Myrtiformes are fleshy eminences found at
the mouth of the vagina, the result of sloughing and cicatriza-
tion after childbirth, and are not, as formerly supposed, the
remains of a ruptured hymen.
h. The Fossa Navicularis is a depression formed between the
hymen and fourchette, when the labia majora are drawn apart.
2. The Vagina is a musculo- membranous canal situated
between the rectum and bladder, and connects the pudenda with
the uterus, It runs obliquely upwards and backwards, its
e glans,
by to a
of the
AVernous
er which
each side
its apex
, of this
1e meatus
limple or
yin intro-
onnective
ely sur-
found at
cicatriza-
osed, the
ween the
vn apart.
situated
nda with
ards, its
of the
le and
middle
ommis-
ogous to
commis-
OBSTETRICS. 3
anterior and posterior wal\s being in contact with one
another. Its length is anteriuciy 24 in. and posteriorly 34 in.
The fornix or upper part encircles the cervix uteri, extending
higher on its posterior than its anterior aspect. It has three
coats, mucous, muscular (consisting of circular and longitudinal
fibres) and fibrous. A circular bundle of muscular fibres sur-
rounds the lower part and is called the sphincter cunne.
The mucous membrane is thrown into folds or transverse
ridges which are well marked in virgins, especially on the
anterior wall, but become obliterated in multipare and in old
age.
II. INTERNAL.
1. The Uterus is a pear-shaped, thick-walled, hollow organ,
flattened antero-posteriorly, convex behind, and plain in front.
® Tt differs in the virgin and in multipare. It consists of fundus,
body and neck ; measures 3 in. in length, 2 in. in breadth, and
one inch in thickness. It weighs 1 oz. Its cavity is triangular
and opens laterally into the fallopian tubes by orifices 1-25 in.
in size.
The lower extremity or cervix projects into the vagina, and
presents a transverse aperture called the os tincee, from its fancied
resemblance to a tench’s mouth. The os is bounded by two
thick lips, of which the anterior is longer than the posterior,
The cavity of the cervix extends from the external to the inter-
nal os, and its mucous membrane presents folds called the arbor
| vite, and contains a large number of giands called the follicles
of Naboth.
The peritoneum is reflected over the uterus, covering it
anteriorly and posteriorly, meeting at the lateral borders and
spreading to the ilia of each side, dividing the pelvis into two
halves, and constituting the ligamenta lata, or broad ligaments.
The round ligaments are two bands of smooth, muscular and
elastic fibres, which extend first into the broad ligament, then |
4 OBSTETRICS.
pass outwards and forwards, enter the inguinal canal with the 2.
epigastric artery, and are attached to the tissue of the labia the u
majora. They were the former inguinal ligaments of the folds
Wolffian bodies,
ting ¢
On the posterior surface the peritoneum descends over the ity 0
supra-vaginal portion of the uterus, and over that portion of the large
vagina which covers the posterior lip of the intra-vaginal por- af
tion, then becoming continuous with the peritoneal investment One,
of the rectum, This forms a deep excavation between the uterus angl
and the rectum, called the cul-de-sac of Douglas. eg
The uterus possesses a large degree of mobility, and its posi- oe
tion is largely influenced by neighboring organs: thus, a full tot
bladder pushes the fundus backwards ; a full rectum pushes the 3
cervix forwards, etc.
on €
The muscular fibres of the uterus are arranged in three layers pro
The superficial covers the back and front like a hood, leaving ant
the sides free; the median layer forms the great bulk of the bor
walls, the fibres being longitudinal and transverse ; while the of 1
) inner layer is circular and insignificant. The mucous membrane one
4 measures 1-25 in. in thickness, is covered with an alkaline r
i mucous and when slightly magnified presents the orifices of the ay :
uterine glands which extend through the whole thickness of the
Ve mucous membrane. The mucous membrane of the body of the |
‘e uterus is covered with ciliated epithelium producing a current bi
| i towards the fallopian tubes. | a
; Hi The mucous membrane of the cervix is of a yellowish red
ay color, firm, and presents ruge. It is covered with columnar ai
\ epithelium, and tubular glands are present in large numbers, nm
r the Nabothian follicles, ‘3
Hi The blood vessels to the uterus are the uterine from the la
hypogastric and aorta, which pass over to the cervix and ascend of
to the uterus.
h the
labia
f the
r the
of the
1 por-
tment
terus
posi-
a full
es the
ayers
aving
f the
e the:
brane
caline
of the
f the
f the
rrent
1 red
mnar
bers,
the
cend
OBSTETRICS. 5
2. The Fallopian Tubes pass outwards from the fundus of
the uterus laterally. They are 3 to 4 in. long, contained in the
folds of the broad ligament, and consist of the isthmus, admit-
ting a bristle, the ampula admitting a sound, and a free extrem-
ity or pavilion communicating with the abdominal cavity and
large enough to admit a small goose quill. The free extremity
is surrounded by 10 to 15 fimbrie all of which are free but
one, which is larger than the others, and is attached to the outer
angle of the ovary presenting a little gutter or furrow from the
ovary to the opening of the tube. The fallopian tubes consist
of a peritoneal, fibrous, muscular and mucous coat, the last
arranged in folds and covered with ciliated epithelium, the direc-
tion of the current being from the ovary to the uterus.
3. The Ovaries are two flattened, nearly ovoid bodies which lie
on each side of the uterus, attached to the broad ligameut, and
project from its posterior surface. They are about the size of
an almond, 1} in. long, in. broad, and } in. thick. Their outer
border next the broad ligament presents a hilum for the passage
of vessels. The outer extremity is rounded and attached to
one of the fimbriz of the fallopian tube.
The inner extremity is pointed and attached to the side of the
uterus by the ovarian ligament.
Each ovary weighs 75 grains. The surface is marked by
rounded translucent elevations produced by distended Graaffian
follicles and often cicatrices and corpora lutea in various stages
of atrophy.
Externally the ovary is surrounded by a fibrous coating
called the tunica albuginea which is internally adherent to the
subjacent tissues. Beneath this the parenchyma of the ovary
is divided into a cortical and medullary substance. The medul-
lary substance is reddish and spongy and contains an abundance
of blood vessels.
The cortical portion is of a grayish color and consists of lay-
6 OBSTETRICS,
ers of connective tissue continuous with the medullary portion,
and imbedded in this layer is a multitude of Graaffian follicles.
The Graafian Follicles contain the ova, and at certain periods
they enlarge, approach the surface of the ovary, and finally rvp-
ture, discharging their contents, which are carried by the vortex
into the fimbriated extremity of the fallopian tube. These fol-
licles exist only in the cortical substance of the ovary where they
number several thousands, some of which never reach maturity.
Though they exist from the earliest period of childhood, and
even before birth, yet it is only at the age of puberty that the
important stage in their development is noticed. Then from 12
to 30 of them enlarge, so that at that period we have all sizes
between the smallest primordial follicle 1-800 in. and the largest
nearly } in. in size. In the fully sized follicles we have fully
developed ova, one or very rarely two, of the pretty uniform
diameter of 1-125th of an inch.
In the largest follicles then we have an outer layer of connec-
tive tissue called the tunica propria, which islined with epithelial
cells called the membrana granulosa, and at a certain point in
this membrane is a mass of cells called the discus or cumulus
proligerus in which the ovum is embedded.
The follicle also contains a liquid which is alkaline, slightly
yello. 1, not viscid, and containing a small quantity of album-
inoid matter coagulable by heat.
The Parovarium or organ of Rosenmiiller is the remains of
the Wolffian body tying in the folds of the broad ligament
between the ovary and the fallopian tube. It consists of from
12 to 15 tubes of fibrous tissue lined by ciliated epithelium and
is often the seat of so-called Parovarian cysts.
The Germ Cell or Ovum when ripe is 1-125 in. in size, glob-
ular in shape and consists of :—
(a). Zona Pellucida, or external membrane, clear, structure-
less, strong and resisting, 1-2,500 in. in thickness. This with
connec-
vithelial
int in
umulus
slightly
album-
ains of
yament
of from
m and
glob-
cture-
3 with
OBSTETRICS. 7
radiating striations becomes the vitelline membrane. — In fishes
and molluscs there exists a micropyle or porus for the passage
of the spermatozoa, and though this has not been demonstrated
in the mammalia or in man, it probably exists.
(6). The Vitellus, c lled tne principal or formative yolk,
contains the elements which are to undergo development into
the embryo. It is a semi-fluid mass containing besides the ger-
minal ve-%cie, numerous granules which are large strongly-
refracti::. .‘obular bodies, very bright ; and between these are
smaller and not so distinct albuminous granules.
(c). The Germinal Vesicle is the enlarged nucleus of the
primordial ovum, and is clear, globular, 1-700 in. in size, em-
bedded in the vitellus, its position varying. In its interior are
a number of fine granules and a large dark spot,
(d). The Germinal Spot, which is 1-3,000 in. in size.
ITI. PERIODICAL OVULATION.
1. The Discharge of the Ovum. A ripe Graaffian fcl-
licle about 2 5 in. in size presents a rounded elevation with en-
larged blood vessels upon the surface of the ovary, and at the
most prominent portion is an ovoid spot which is entirely free
from blood vessels, called the macula folliculi, where for a time
before rupture a process of fatty degeneration is going on. At
' the same time at other portions of the follicle there is a growth
of cells which projects into the interior, as well as an extension
of blood vessels in the form of loops. These changes, together
with the increase in pressure of the liquid contained in the fol-
licle, causes the latter to burst, and with the liquid the discus
proligerus and ovum are expelled.
The periodical ripening of the ova and their discharge consti-
tutes “ovulation ” and may be considered as the primary act
of reproduction. It is necessary to bear in mind then tl it the
ova exist originally in the ovaries as part of their natural struc-
8 OBSTETRICS.
ture ; that they only become fully developed at a certain age,
viz: that of puberty, when the generative function is about to
be established ; that successive crops of these ova ripen and are
discharged in the adult female independently of sexual inter-
course. Furthermore the ripening and discharge of the ovum
are acconipanied by a peculiar condition of the general system
known in the lower animals as “rutting” and in the human
female as menstruation.
2. Menstruation. During infancy and childhood the sex-
ual system is inactive, but at the age of 14 or 15 the human female
undergoes a remarkable change and arrives at what is termed
the age of puberty. There is then a marked increase in the
general development of the body ; the limbs become fuller and
more rounded ; a growth of hair appears upon the mons veneris ;
the mammary glands increase in size and take on a new stage
of development ; Graaffian follicles enlarge and appear ready to
rupture. At this time is also noticed a change in the moral as
welPas the physical attributes of the female ; a seeming consci-
ousness of a capacity for new functions and a change in feeling
towards the opposite sex which gives rise to that modesty so
becoming and lovely in the true woman.
The female now becomes capable of impregnation and con-
tinues so, in the absence of pathological conditions, until the
final cessation of the menses, known as the menopause or climac-
teric which usually occurs at 45 years of age. Puberty occurs
earlier in warm than cold climates, and its onset is SREY in
some girls than in others.
Together with these changes then in the female at puberty
a discharge or flow from-the genital organs is established, and
this recurs every 28 days, corresponding to the period of dis-
charge of the ovum. Each period begins with a feeling of gen-
eral malaise, a sense of fulness and weight in the pelvic organs,
and an increase of vaginal mucus, which has a peculiar fishy
im odour
whic
an avé
ally l¢
mem|
smeal
1-51
enlar:
mem
Exce
true
tion
tain age, §
bout to
and are
al inter-
e ovum
1 system
e human
the sex-
n female
s termed
e in the
ller and
veneris ;
bw Stage
ready to
moral as
g consci-
n feeling
lesty so
nd con-
ntil the
‘ climac-
y occurs
rlier in
puberty
ied, and
of dis-
of gen-
organs,
r fishy
® lation.
| time impregnation is most apt to, take place.
= menstruation and usually removes sexual desire.
when disvharged from the ovary enters the fimbriated extremity
OBSTETRICS. 9
odour. These feelings are soon relieved by a discharge of blood
which is usually kept fluid by the acid vaginal mucus. It lasts on
anaverage four days, and measures about 6 oz., becoming gradu-
ally less in amount, and lighter in color until it stops. The mucous
membrane of the uterus at this .ime is thicker and softer and
smeared with blood. From the 1-25 in. in thickness it becomes
1-5in. thick, loosely attached, tirown into folds, and its glands
enlarge. A fatty degeneration of the surface of the mucous
membrane and of its blood vessels gives rise to the hemorrhage.
Except a considerable desquamation of epithelium there is no
true exfoliation of the mucous membrane in normal menstrua-
tion although there is in membranous dysmenorrhea.
The process of menstruation may be thus explained: An
ovum ripens; the swelling of the Graaffian follicle irritates
# the nerve termini in the ovary, which irritation is propagated
to the central organs. Through reflexes by vaso-motor pro-
cesses an arterial congestion of the internal female sexual organs
is set up. This in turn increases the liquor folliculi, so that
the theca folliculi bursts and allows the ovum to escape,—ovu-
At the same time the uterine mucosa becomes so hyper-
emic that there occurs a bursting of the peripheral vessels,
hemorrhage occurs upon the surface of the uterine mucous mem-
brane, constituting menstruation. It is immediately after the
menses that sexual desire is decidedly marked and at this
As we should
naturally expect removal of the ovaries prevents ovulation and
The ovum
of the fallopian tube, the fimbrie being covered with vibratile
ciliated epithelium, inciting a kind of vortex in the peritoneal
§ fluid which carries toward and into the tube everything lying
near it. Thisis seen experimentally in the lower animals with
coloring matter which is even drawn from one side to the other
;when the opposite tube is occluded. The ovum then passes
10 OBSTETRICS.
along the tube to the uterus by the movement of the ciliated
epithelium. Accidental causes may arrest it at the surface of
the ovary, and if impregnated, give rise to ‘ovarian preg-
nancy ;” if it drops into the abdominal cavity, we have
“abdominal pregnancy,” or i. arrested in the fallopian tube,
“ tubal pregnancy.”
If sexual intercourse do not take place the ovum passes down §
to the uterus unimpregnated, loses its vitality after a short time
and is carried away with the uterine discharges. The menstrual §
flow is therefore only the external manifestation of a more §
important process taking place within. Its disorders constitute
amenorrhea, dysmenorrhea. and menorrhagia.
3. The Corpus Luteum. Let us see now what takes place
in the Graaffian follicle after the expulsion of the ovum. Its §
office of providing for the formation and growth of the ovam is §
now over and it passes through a process of oblitccation. The
bloody cavity left becomes converted into a peculiar svulid spher-
oidal body called the corpus luteum, the growth and retroces-
sion of which are modified by pregnancy, 30 that we have two
varieties, that of menstruation and that of pregnancy.
(a). The Corpus Luteum of Menstruation, often called the
false corpus luteum. After rupture, blood fills the cavity of
the Graaffian follicle and soon coagulates. This begins to con-
tract and the serum separates from the clot and is absorbed,
while the clot becomes smaller and denser, and its coloring mat-
ter becomes partially absorbed. At the same time the vesicular
membrane becomes thickened and convoluted, beginning at the
deeper part of the follicle. This hypertrophy reaches its maxi-
mum at the end of three weeks, and the ruptured follicle has
now become completely solidified, showing a prominence upon
the ovary and a minute cicatrix. After -this it diminishes in
size, its central coagulum continues to be absorbed, loses still
.its coloring matter, and the whole goes on atrophying. The
| lute
deve
uter
men
he ciliated
surface of
rian preg-
we have
bian tube,
sses down §
short time
menstrual §
bf a more &
constitute
akes place
vum. Its §
le OVam is §
ion. The
vlid spher-
d retroces-
have two
called the
cavity of
ns to con-
absorbed,
ring mat-
> vesicular
ing at the
its maxi-
ollicle has
ence upon
nishes in
loses still
ing. The
OBSTETRICS. ll
convoluted wall assumes a more decidedly yellow color, under-
goes fatty degeneration and at the end of eight or nine weeks
the whole is reduced to an insignificant yellowish cicatricial
mark, and finally all traces of it disappear. At a post mortem
several of these may be seen in various stages of growth and
atrophy. |
Such then is the process that takes place independently of
sexual intercourse or impregnation.
(b). The Corpus Luteum of Pregnancy. The true corpus
luteum presents a difference in the rapidity and degree of its
development, due to the sympathy which exists between the
uterus @ .’ the ovaries. As soon as pregnancy takes place
menstruation is arrested, no “ore ova come to maturity and no
more Graaffian follicles are ruptured during the whole period
of gestation. Hence we might expect that the corpus luteum
would be affected by an influence which affects the system in
general so profoundly.
During the first three weeks its growth is the same as the
false variety, but during the fourth week instead of retrograd-
ing it continues developing, the external wall growing thicker
and more convoluted. This growth goes on until by the third
and fourth month it reaches its maximum, about the sixth
month it begins to retrograde, and after delivery atrophy goes
on rapidly, and after lactation has come to an end the ovaries
resume their ordinary function as before. \
IV. FACUNDATION OF THE OVUM.
The last change and one which indicates its complete maturity,
is, that the germinal vesicle comes to the surface and disappears
from view, as also the germinal spot. In place of the germinal
vesicle a spindlc-shaped body appears. The granular elements
| of the vitellus arrange themselves around each of the two poles
of the spindle in the form of astar. When this takes place the
peripheral pole of the nucleus or altered germinal vesicle, along
12 OBSTETRICS.
with some of the cellular substance of the ovum, protrude upon Th
the surface of the vitellus, where they are nipped off from the §@ or not
ovum in the form of small corpuscles jus; like an excretory pro- # tain {
duct. These bodies, which are not made use of in the further #§ and o
development and growth of the ovum, are called polar or direct- 1.
ing globules. The remaining part of the germinal vesicle stays 7 j,; the
within the vitellus and travels back towards the centre of the & ,itell.
ovum to form the female pronucleus. As a rule only one sper- & the c:
matozoon penetrates the ovum and as it does so it moves @ 4 Jars
towards the female pronucleus while its head becomes surroun- and i
ded with a star; it then loses its head and tail, the latter only J ance,
serving as a motor organ while the remaining middle piece MH dence
swells up to form a second new nucleus, the male protonucleus. 2.
The union of these two elements forms the first embryonic seg- @ ., gm
mentation sphere or blasto-sphere. (Landois). 32,
Should union of the sexes have taken place by the fusion of polys
the germ cell and sperm cell, a new stimulus is imparted to the & being
growth of the former, and the fecundated ovum starts on a
peculiar course of development by which it is rae converted
into the body of the young animal.
covel
vitel
T
Many questions of great interest arise in connection with fj #bou
fecundation such as hereditary influence ; maternal influence; J 20°
the
Ba CCl
determination of sex, and effect of previous pregnancies,
V. DEVELOPMENT OF THE OVUM.
It is probable then that the ovum is fecundated either in the
fallopian tube or in the pavilion near the ovary. The ovum as
it passes down the fallopian tube becomes covered with an
albuminous secretion which in birds is very abundant and con-
stitutes the “ white of egg.” This serves to protect and nourish
the ovum for a short time, and if the spermatozoa have not pene-
trated the vitelline membrane near the ovary, it prevents their
doing so now.
ide upon @
from the §
ory pro-
p further
br direct-
cle stays
re of the
one sper-
it moves
surroun -
tter only
dle piece
pnucleus.
onic seg-
fusion of
ed to the
arts on a
converted
ion with
influence ;
8,
her in the
2 ovum as
with an
; and con-
id nourish
not pene-
ents their
OBSTETRICS. 13
The next thing noticed, whether the ovum has been fecuncdated
or not, is that the vitellus gradually withdraws itself from cer-
tain portions of the vitelline membrane or becomes deformed
and often rotates upon itself by amceboid motion.
1. We have said the sign of complete maturity of the ovum
is the disappearance of the germinative vesicle. The deformed
vitellus resumes its original rounded appearance and again fills
the cavity of the vitelline membrane. The granules collect in
a large zone around the centre of a clear spot in the vitellus
and in the centre itself a clear rounded body makes its appear-
ance, called the nucleus of the vitellus. This is positive evi-
dence of fecundation:and appears at from 15 to 30 hours.
2. Segmentation ofthe Vitellus. Almost immediately,
segmentation takes place, the vitellus dividing into 2, 4, 8, 16,
32, 64, etc., until the whole forms an external membrane of
polygonal cells containing a small quantity of fluid, the former
being called the blastodermic membrane. The albuminous
covering of the ovum gradually liquifies and is absorbed by the
vitelline membrane for the nourishment of the vitellus.
The ovum now passes from the fallopian tube into the uterus
about the eighth day after fecundation, having increased in size
about 5 times, and being now composed of an external covering,
the vitelline membrane, then the blastodermic membrane, and
| a certain amount of fluid in its interior.
Soon after the formation of the blastodermic membrane, at a
certain point on its surface appears a rounded elevation or heap
of cells called the embryonic spot which soon becomes elongated
or oval, is then surrounded by a clear oval area called the area
pellucida, with a dark line in its centre called the primitive
trace. The latter afterwards becomes the headfold and groove
for the neural canal.
Next the blastodermic membrane separates into two layers,
an external or .serous called the epiblast, and an internal or
14 OBSTETRICS.
mucous called the hypoblast. The layers thicken at the prim-
itive groove and by elevation of ridges and their union posteri-
orly canal for the spinal cord is formed. th Sees
At. » same time another layer is fox med from the inner sur-
face of the 6xternal layer, and the adjoining surface of the inter-
nal layer, called the mesoblast. From the epiblast are devel-
oped the epidermis and its appendages, the great nerve centres,
the principal parts of the eye, ear, nose aud one layer of the |
amnion.
From the hypoblast are formed the epithelial lining of the
whole alimentary canal and of the lungs, and one layer of the
allantois. From the mesoblast are formed the bones, muscles, §
fascie, peripheral nerves, vascular system, connective tissue,
muscular coat of the alimentary canal, the outer layer of the
amnion, and the other layer of the allantois.
3. The Formation of the Membranes. As the ovum
is received into the uterus the vitelline membrane developes
upon its surface little villosities formed of amorphous matter
with granules, but non-vascular, and not permanent, merely |
assisting in fixing the ovum to the uterine cavity.
At this time a fold of the external layer makes its appearance,
most prominent at the cephalic and caudal extremity of the
neural canal, which gradually increases, passing over the dorsal
surface of the embryo, and finally meets so as to completely
enclose the embryo ; and this is called the amnion. When it
has been completely formed, the vitelline membrane has been
encroached upon by the external amniotic membrane and 4is-
appears, leaving this layer of the amnion as the external cover-
ing of the ovum which still possesses non-vascular villosities,
Soon after the development of the amnion, the allantois is
formed, before the two layers of the amnion have fused, It
appears as a small pear-shaped vesicle which springs from the
mucous layer near the caudal extremity of the embryo, It rap-
the prim-
bn posteri-
inner sur-
the inter-
are devel-
e centres,
yer of the
ng of the
yer of the
8, muscles, §
ve tissue,
yer of the
3 the ovum
developes
us matter
at, merely |
ppearance,
ity of the
the dorsal
sompletely
When it
) has been
e and dis-
nal cover-
losities.
Jlantois is
fused, It
| from the
. Tt rap-
# suspended the embryo.
speci BP,
9
OBSTETRICS. 15
idly increases until it forms a membrane of two layers situated
between the two layers of the amnion. It becomes vascular and
very soon encloses the internal layer of the amnion and the
embryo. Then the two layers of the allantois blend into one,
invade, and supercede the external layer of the amnion, becoming
now the external layer of the ovum and called the chorion.
That portion of the allantois included in the embryo forms the
bladder and is connected for a time with the rest of the allantois
@ by the urachus.
The allantois is a vascular membrane, at first containing two
arteries and two veins. The arteries persist and form the two
arteries of the umbilical cord, but the right vein becomes oblit-
erated, the left remaining as the umbilical vein. These vessels
are connected with the permanent vascular tufts of the chorion.
While this is going on the blastodermic vesicle becomes
divided into .wo parts, the lower being embryonic, the layer
above forming the wmbilical vesicle which is cut off as it were
from the abdominal cavity, but still communicates freely with
the intestine. It gradually diminishes as the embryo increases
and becomes farther removed from the embryo by elongation of
its pedicle and finally becomes compressed between the amnion
and chorion.
The chorion now becomes marked by a multitude of compound
villi over its whole surface which gives it a shaggy appearance.
The amnion is separated from the chorion by a gelatinous layer
in which is embedded the umbilical vesicle, but the former
gradually disappears until about the fourth month the amnion
comes in contact with the internal surface of the chorion, when.
it forms a lining for the chorion and secretes a fluid in which is
The amniotic fluid consists of water,
albumen, urea and various salts, and has great power of resisting
putrefaction. The uses of the liquor amnii are to facilitate the
devalopment and maintain the form of the ovum and uterus; to
protect the embryo from pressure aud lessen thks influence of
ee
ee eee IDES Sg SO
16 OBSTETRICS.
falls, blows, and other accidents to the mother ; to facilitate the
growth of the foetus and allow of its active motions ; to aid the
dilatation of the os uteri during labor, and after the membranes
are ruptured to favor relaxation of the vagina and perineum,
thus facilitating the passage of the child and the easier perfor-
mance of obstetric operations.
The amnion then gradually becomes distended by increase
in the quantity of amniotic fluid and reaches the internal surface
of the chorion about the end of the fourth month, and extends §
over the umbilical cord to form its external covering.
4. Preparation ofthe Uterus to receive the Ovum.
As the fecundated ovum enters the uterus, being shaggy with
the villosities of the chorion, it becomes engaged in one of the
furrows of the hypertrophied mucous membrane of the uterus.
The hypertrophied mucous membrane lining the uterus is called §
the decidua vera, and the new growth springing from the border
of the furrow in which the ovum is received is called the decidua
reflexa, because it folds over and finally envelopes completely |
the ovum. That part of the decidua vera which afterwards
becomes the placenta is called decidua serotina.
These changes do not take place in the mucous membrane of
the cervix uteri, the glands there secreting a semi-solid trans-
parent viscid mucus, which closes the os and is called the uterine
plug.
Afterwards both decidua vera and reflexa diminish in activity
of growth, and lose their importance as 2 means ot nourishment
for the embryo, while that part in contact with the vascular
tufts of the chorion continues to grow and finally takes part in
the formation of the placenta. |
5. Formation of the Placenta. Our knowledge of
the development and structure of the placenta is derived largely
from its study in the lower animals.
litate the
to aid the
embranes
perineum,
ier perfor-
y increase
nal surface
e Ovum.
aggy with
ne of the
he uterus,
the border
he decidua
completely }
afterwards
mbrane of
olid trans-
the uterine
in activity
urishment
> vascular
68 part in
wledye of
ed largely
d extends §
s is called &
OBSTETRICS. 17
The villi of the chorion all atrophy except at that part which
is to become the placenta. These villi penetrate into the fol-
licles of the uterine mucous membrane and become developed
into a tufted capillary loop. At the same time the uterine fol-
licle into which the villus has penetrated enlarges, sending out
branching diverticuli corresponding to the ramifications of the
villus, Every uterine follicle is soon covered with a network
of dilated capillaries, which enlarge, and encroaching upon the
spaces between them, fuse and become dilated into sinuses
which communicate with the arteries in the muscular wall of
the uterus, the sinuses extending through its whole thickness.
The vascular tufts of the chorion still grow outwards and extend
through the entire thickness of the placenta. By and bye the
four membranes fuse into one, viz: the membrane of the fetal
villus, that of the uterine follicle, the wall of the foetal blood-
vessel and the wall of the uterine sinus. So that the tufts of
the foetal blood-vessels are bathed in the blood of the maternal
sinuses, by which means both absorption and exhalation go on,
but there is no direct communication.
At the end of the third month the limits of the placenta
hecome distinct and the organ soon becomes fully developed.
At the full period it occupies nearly one third of the uterine
mucous membrane, is round or ovoid with thin edges, measures
7 to 9 in. in diameter and weighs from 15 to 30 oz.
Its foetal surface is covered with smooth amniotic membrane
and its uterine surface is rough and divided into irregular lobes
or cotyledons separated by dissepiments.
The uterine arteries enter the maternal sinuses obliquely, so
that when the uterus contracts after delivery and expulsion of
the placenta these vessels are more completely closed by the
muscular contraction.
The functions of the placenta are :—es a respiratory organ
it provides for the interchange of gases between the fcetal and
3
18 OBSTETRICS.
maternal blood ; as an organ of nutrition the epithelial cells
of the foetal villi possess a selective power and absorb nutri-
ment, and it is in this way that medicines are absorbed and
zymotic diseases communicated; while as an excretory organ,
urea is eliminated so that it discharges the function of the
kidneys, and lastly it possesses a glycogenic function until the
liver is sufficiently developed to undertake that work.
. Lhe Umbilical Cord. The attachment of the embryo to the
investing membranes of the ovum is at first a short and wide
funnel-shaped connection, consisting of the .commencement of
the chorion, part of the amnion, and between the two a gela-
tinous material containing the stem of the umbilical vesicle.
As the amniotic cavity enlarges the embryo recedes and its
connecting part elongates, beginning to present the appearance
of a cord, and as it emerges from the embryo at a point where
the abdominal walls afterwards close round it to form the
umbilicus it is called the umbilical cord. The fully developed
cord is about the thickness of the finger, about 20 in. long, its
external covering being the amnion, beneath it a gelatinous
layer, the gelatine of Whorton, which surrounds the two arteries
and vein protecting them from compression or obliteration.
The arteries are twisted round the vein, and the cord itself is
often twisted. The cord also contains the relic of the umbilical
vesicle and the urachus, which is the connection between the
allantois and bladder.
The decidua reflexa is being constantly distended by the
growth of the ovum, and is finally pressed against the opposing
surface of the decidua vera, so that by the end of the seventh
month they are in contact and soon blend so as to form a single
thin friable semi-opaque layer in which no trace of glandular
structure can be discovered.
During the process of development then the product of fecun-
dation is nourished, first as an ovum by the albuminous secre-
tion ¢
by th
1.
calle
calle
place
a foe!
TI
taine
inal
ial cells
D nutri-
bed and
y organ,
of the
ntil the
p to the
nd wide
ment of
ba gela-
vesicle.
and its
pearance
t where
brm the
pveloped
long, its
latinous
arteries
eration.
itself is
mbilical
een the
by the
pposing
seventh
a single
andular
f fecun-
8 secre-
OBSTETRICS. 19
tion on its surface, then by the ‘umbilical vesicle ; as an embryo
by the villi of the chorion, and as a foetus by the placenta.
VI. DEVELOPMENT OF THE EMBRYO.
1. Of its Various Parts. The product of fecundation is
called an ovum until some form becomes apparent, and then it is
called an embryo, and after the third month, at the time the
placenta has formed and quickening is about to occur, it is called
a foetus and retains that name until delivery.
The bladder is formed from that portion of the allantois con-
tained in the abdominal cavity after the closure of the abdom-
inal plates. |
The intestine is at first « straight tube and becomes convelu-
ted. The anus is at first closed. The liver buds from the
intestine.
The front of the upper part of the body is open and develops
by four arches, the first forming the face and bones of the ear,
the second and third forming the hyoid bone and parts adjacent,
while the fourth forms the larynx. At first the face is open as
far back as the ears, and cleft palate is thus caused by a defici-
ency in the union of the lamelle which form the palatine arch.
The genital and urinary organs are preceded by two large
symmetrical structures called the Wolffian bodies, which at about
the 30th day develop rapidly at each side of the spinal column
and are as large as to almost fill the cavity of the abdomen.
Very soon two ovoid bodies appear at their side, the testes in
the male, the ovaries in the female. At the external border
are two ducts, one of which in the male becomes the vas defer-
ens and in the female the fallopian tube. The kidmeys are
behind and until they are fully developed their office is under-
taken by the Wolffian bodies. The scrotum corresponds to the
v
labia and hence inguinal shernia in the female passes down
into the labia.
20 OBSTETRICS
2. Asa Whole.—V/irst Month (4th week). Its length is
4 lines, weighs 20 grains, size of a maggot or barley corn, and
the form of a serpent coiled. The mouth on the cephalic
extremity appears as a cleft, and the eyes as two black points.
Nipple-like protuberances mark the position of the extremities.
The heart can be seen and the liver is disproportionately
large.
Second Month (8th week). It measures 15 to 18 lines and
weighs from 2 to 5 drachms. Is the size of a kidney-bean.
The head is disproportionately large. The nose, lips and exter-
nal parts of generation are visible, The anus appears as a dark
point. The abdomen encloses the internal organs. The extrem-
ities project slightly from the trunk. Ossification occurs in the
clavicle and lower jaw about the end of the seventh week ; in
the frontal bone and ribs, towards the end of the eighth week.
Third Month (12th week). It measures 2 to 4 inches and
weighs 1 to 2 ounces. The eyes and mouth are closed, the
fingers well separated, the nails recognizable, the sex can be
detected by the aid of a lens, the supra-renal capsules and thy-
mus gland are formed, the cavities of the heart and divisions of
the hrain are distinct, the placenta is isolated, the umbilical
vesicle, allantois, etc., have disappeared, and the membranes are
larger than a goose egg.
Fourth Month (16th week). It measures 5 to 6 inches and
weighs from 2} to 3 ounces. The skin is rosy and tolerably
dense, the sex is seen without the aid of a lens, the mouth is |
large and open, the umbilicus is near the pubis, the large intes-
tine contains a greyish white meconium, and the muscles pos-
sess contractility.
Fifth Month (20th week). It measures 10 to 11 inches and
weighs from 6 to 10 ounces. From the fifth month on the
length of the foetus is approximately exactly double the number
of lunar months. ‘The nails are distinct, the head, liver, heart
hod Sis ae
RD PAO ee a, Tees A\ ine eee.
ngth is
rn, and
ephalic
points.
emities.
ionately
nes and
ey-bean.
d exter-
is a dark
b extrem-
rs in the
eek ; in
th week.
ches and
sed, the
kK can be
and thy-
risions of
umbilical
‘anes are
ches and
tolerabl}
mouth
ge intes-
cles pos-
ches and
. on the
number
er, heart
OBSTETRICS.
and kidneys are disproportionately large. Hair appears as a
light down, meconium is of a yellowish-green color, and points of
ossification appear in the pubis and os calcis.
Siath Month (24th week). It measures 12 inches and weighs
1 to 2 pounds. Down and sebaceous matter cover the skin, the
skin is of a cinnabar red color and the umbilicus is further from
the pubis, the meconium is of a darker color, the scrotum is
empty, the testes being close to the kidneys, the pupillary mem-
brane is still present and the prepuce has appeared.
Seventh Month (28th week). It measures 14 inches and
weighs 3 to 4 pounds. The skin is of a dirty red color, the hair
is half an inch long and plentiful, the pupillary membrane is
disappoaring, the eyelids are non-adherent, meconium is of a
dark olive-green, the fontane’ies are distinctly felt, the liver is
still large, and the foetus is now ‘ viable,” j. e., capable of main-
taining a distinct existence from the mother.
Eighth Month (32nd week). It measures 16 inches and
weighs 4 to 5 pounds. The skin is more of a rosy flesh color
and is covered with soft hair, the pupillary membrane has dis-
appeared and the testes have descended into the scrotum. The
open vulva disclose the clitoris to view. The nails almost
reach the tips of the fingers, the eyelids are open and the cornea
is transparent.
Ninth Month (36th week). It measures 18 inches and
weighs 6 pounds. The head is covered with hair, the down on
the body is disappearing, the scrotum is corrugated and the
vulva closing.
Tenth Month (40th week), nine calendar months. It
measures 20 inches and weighs from 7 to10 pounds. The skin
is firm, not wrinkled, the fontanelles are large, hair on head, the
nails are hard and reach the tips of the fingers, and the cartil-
ages of the ears feel elastic. The true sign of complete maturity
is the appearance of a centre of ossification in the inferior
22 OBSTETRICS.
extremity of the femur; this may be of use in medico-legal rule
cases to determine the maturity of a dead child. To find it si.
make a horizontal incision through the knee joint, remove the the
patella and make thin slices until a colored point is found, and inte
still carefully slice, until a red spot is noticed. This osseous mel
nucleus measures from # to 3 lines in diameter. atte
J
B.—PREGNANCY. ss
I. CHANGES OCCURRING IN THE MOTHER. [§ 2"
1. Inthe Sexual Apparatus. The wterws increases in Si
vascularity, the arteries increasing in size and becoming tor- me
tuous. The veins dilate and become intimately united with the ‘hie
_ walls of the uterns. The mucous membrane becomes soft and
thickened, and the muscular fibres increase in size and amount.
The uterus increases in weight from 1 ounce to 2 pounds. At
first this increase is %t due to expansion of the ovum, for the
same change occurs duriny the first four months in extra-uterine
pregnancy ; later on, however, it is due to expansion from pres- |
sure of its contents. In the early months of pregnancy the |
increase of the size of the uterus is in the antero-posterior and
lateral, rather than in the longitudinal diameter, so that it is
not until the fourth month that the fundus can be felt through
the abdominal wall above the symphysis pubis. At the fifth
month it fills the hypogastric region, and at the ninth month it
reaches the epigastrium. During the lart two weeks it sinks
in the pelvis.
The cervix also hypertrophies, but its development is com- |
pleted by the fourth month and is the result rather of loosening
of its structure and swelling from serous infiltration due to
hyperemia. An apparent shortening of the cervix takes place,
which was thought to be due to a gradual unfolding from above
downwards, as the uterine cavity enlarged ; but no real shorten-
ing takes place, however, for the internal os remains closed, as a
osseous
amount.
ds. At
, for the
a-uterine
om pres-
ancy the
rior and
that it is
through
the fifth
month it
it sinks
is com-
posening
due to
28 place,
m above
shorten-
ed, as a
OBSTETRICS. 23
rule, up to the last two weeks of pregnancy, and the apparent
siortening of the cervix is due to a spindle-shaped dilatation of
the cervical canal causing an approximation of the external and
internal orifices, and also to the swelling of the vaginal mucous
membrane, and of the loose tissue surrounding the vaginal
attachment of the cervix.
In the vagina, the muscular fibres hypertrophy, the veins
increase and give it a blue color, the mucous membrane thickens
and secretes more mucus, and there is thus often a pouting or
protusion of the anterior vaginal wall between the vulva.
The vulva are turgid and the labia gape, the abdominal walls
stretch, the navel protrudes, the linea albicantes appear and
these are also often seen on the thighs.
The mammary glands increase in size, the nipple elongates,
and changes occur in the areola. The capacity of the bladder
is diminished from pressure and there is increased freouency of
urination. Constipation is common, cramps in the legs are fre-
quent from pressure on the sacral nerves, and cedema of the legs
and varicose veins are common.
2. In the System at Large. There is an increase in
the total quantity of blood. The red blood corpuscles, albumen,
iron and salts are diminished, while the white blood corpusctes,
the elements of fibrin, and the water of the blood are increased.
As the amount of blood is increased the balance of the circulation
would require either increased frequency of the heart-beat or
increased capacity of the ventricles. Now as freque.-vy is not
increased the dilatation of the cavities is necessary. So also
arterial tension is increased and the pulse is fuller. As the
heart then has to do more work, eccentric hyertrophy of the left
ventricle takes place.
Then the thyroid gland enlarges, there is an increased amount
of © O, discharged by the lungs, the thorax is increased in
breadth and diminished in depth, the breathing is often
oppressed, indigestion is frequent, especially nausea and vomit-
94 OBSTETRICS.
ing, due to spasmodic contraction of the stomach and diaphragm ;
the appetite is capricious. Besides pigmentation of the areola,
often dirty brown looking spots or patches appear on the face,
especially the eyelids, root of nose and upper lip.
Increased blood pressure causes abundant and watery urine.
The nervous system is very impressionable ; the whole character |
is changed, neuralgic affections are common, the special senses
are otuun disordered, and there is often dizziness and syncope.
IIl.—_THH SIGNS OF PREGNANCY.
In the ear'y periods of pregnancy no decided diagnosis can be
made, but as it advances it is not long before certain phenora-
ena clearly show the presence of theembryo. The signs of prez-
nancy then become a part of every physician’s outfit to be used
as a means of differential diagnosis for the satisfaction of him-
self and his patients; for there are several diseases of the uterus
and its appendages, and of contiguous abdominal organs which
it is essontial to distinguish from pregnancy.
1. Cessation of the Menses. In married women, if pre-
viously healthy, this is a positive sign. In newly married
versons menstruation is often very irregular, so that they may
miss a period and yet not be pregnant. Cases again occur rarely
where menstruation goes on during pregnancy, but it is scanty,
‘comes from the cervix and is likely to be hemorrhagic and fre-
quently results in abortion.
When conception occurs immediately before the menses it
frequently does not arrest the discharge though it usually
diminishes the amount.
All the causes of amenorrhcea must be borne in mind.
2. Mammary Sympathies. Ata very early period of
pregnancy the breasts become full and sensitive and tender.
The superficial veins become larger, and visible under the skin,
sand p
Toward
from th
plasemé
Then
shert a
inent, 4
develoy
darken
becomé¢
3.
the cor
ment ¢
the hy
womal
and oO
clothe:
any 8'
Suk
ment
the w
ulatio
ragm ;
reola,
face,
urine,
racter |
senses
pe.
can be
enoya-
f p res-
e used
f him-
uterus
which
if pre-
larried
y may
rarely
canty,
ad fre.
ses it
sually
OBSTETRICS. 25
Towards the seventh month a serous or milky discharge exudes
from the nipples. These changes, however, may occur in dis-
placements and uterine tumors.
Then after fecundation, the nipple, which in the virgin is
shert and the areola pink, becomes turgid, enlarged, and prom-
inent, and its colorv deepens owing to increased vascularity and
development of the lactiferous tubes. The areola enlarges,
darkens from deposit of pigment, and becomes elevated, soft
j and puffy. The sebaceous follicles of the areola also enlarge and
become prominent.
3. Abdominal Enlargement. After conception and
the consequent uterine development there is a gradual enlarge-
ment of the whole of the lower part of the body, not merely of
the hypogastric region, but also of the sides and nates. The
woman is conscious of a sense of fullness, weight and pressure,
and often. perceives an increase in the size of the waist, her
clothes become too tight and oppressive even before she notices
any swelling in the abdomen.
Subsequently the distension is proportionate to the develop
ment of the uterus, much depending on the size and height of
the woman, her degree of emaciation or obesity, gaseous accum-
ulations in the bowe!s, diseases of liver or spleen, tumors,
dropsy, deformity, quantity of liquor amnii, size of child, or
multiple pregnancy. sa
The enlargement of the abdomen from pregnancy might be
mistaken for other conditions :—
(a). Distension from retained Menses. Here the previous his-
tory an‘ the presence of imperforate hymen or atresia of vagina
or uterus would show what it was. The existence of a pelvic
tumor in a girl who has never menstruated will of itself give
rise to suspicion, as pregnancy under such circumstances is
of extreme rarity. ‘lhen general symptoms will be found to
have existed for a longer period than if pregnancy were
26 OBSTETRICS.
present, such as periodic attacks of pain at the menstrual
periods. There will also be absence of mammary changes and
other signs of pregnancy.
(b). Uterine and Ovarian Tumors. Menstruation does not
cease in ovarian disease and is usually increased in fibroids.
Then the character of the tumor, fluctuation in ovarian tumor,
and the hard nodular masses in fibroid, the history of the
case, the length of time, the absence of cervical softening and
auscultation. There is great difficulty when these growths are
complicated with pregnancy.
(c). Tympanitis, or “ Phantom Tumor,” is recognised by the
percussion-note and the absence of uterine tumor, as demons-
trated by placing the hand on the abdomen and directing the
patient to make alternate deep inspirations and prolonged expi-
rations. During each expiration press the hand more firmly,
until by and bye the hand feels the spinal column and no
intervening body. ) ,
In some cases it is of advantage to put the patient under
chloroform.
4. Ballottement. Is a manipulation by which the foetus
may be felt floating in the fluid contents of the uterus.
The patient lying upon her back, introduce one or two fing-
ers of one hand up to the anterior fornix of the vagina, at the
same time steadying the uterus outside by the other hand.
Then by a sudden impulse of the fingers against the anterior
part of the uterus above the cervix the foetus is felt like a ball
floating loosely in a bag of water. When distinctly felt this is
a positive sign of pregnancy.
5. Quickening. This sign, which simply means the move-
ment of the foetus as felt by the mother, is the first satisfactory §
proof that she is pregnant with a living child. It usually |
occurs at four and a half months, but may be earlier or as late
as the fifth month. The first sensation is trifling and is often
S describ
liar, su
the ha
motions
pation,
The wo
tions O
gastric
muscle:
those o
(a).
detect
o
child is
groin 0
the firs
not de
ing pr
tation
(d).
or bel
mothe
as for
is belli
erecti
of bl
Hence
vous,
uteru
wher
nstrual
ges and
oes not
fibroids,
tumor,
of the
ing and
ths are
l by the
emons-
ing the
pd expi-
firmly,
and no
wt under
ie foetus
wo fing-
, at the
r hand.
interior
© a ball
t this is
e move-
sfactory §
usually |
as late |
is often |
OBSTETRICS. 27
= described as like flatulence, but more frequently as being pecu-
liar, sudden, vibrating or like the fluttering of a bird held in
the hand. As pregnancy advances the intervals of these
motions become shorter, and the sensations more decided. Pal-
pation, especially with a cold hand, often detects motion.
The woman may be deceived by flatulence, corpulency, pulsa-
tions of abdominal aorta, impulse of the heart felt in the epi-
gastric region, aneurism, or irregular action of the abdominal
muscles ; so it is better to trust to your own senses rather than
those of the patient.
6. Auscultation. This may be direct or indirect and by
it we may detect :— .
(a). Pulsations of the Fetal Heart. We can in this way
detect the rhythm, strength and frequency. The average beat
is ra per minute, and it is best heard when the dorsum of the
child is anterior, and is most frequently heard bes+ ~ ar the left
groin of the mother about midway toward the um. :18, bec wse
the first position of the vertex is most common. ~*ould you
not detect the foetal heart sounds, do not be too hasty in deny-
ing pregnancy, nor rashly suppose the child is dead. Auscul-
tation also assists in detecting twins.
(b). Uterine Souffle. This is a murmuring, cooing, hissing,
or bellows-like sound, and corresponds to the pulsations of the
mother’s vessels; hence it is really dependent, not on the placenta
as formerly supposed, but on the blood-vessels of the uterus. It
is believed that duringgpregnancy the uterus is analogous to an
erectile tissue, and that the sound depends on the rapid passage
of blood from the arterial into the distended venous sinuses.
Hence when the circulation is excited, or the mother very ner-
vous, the sound can be detected over the whole body of the
uterus, but it is generally confined to that portion of the uterus
where the placenta is located, and the circulation is most active.
a ee
—
28 OBSTETRICS.
This sound may not be detected at all in some cases, or it may
appear and disappear. As an auxilliary sign it is one of
importance.
7. Jacquemier’s Test. The violet color of the vulva and
vagina is due to the pressure of the uterus on the large veins of
the pelvis. It can often be seen early in pregnancy upon the
cervix, but this may also arise from a tumor.
8. Intermittent Uterine Contractions. These pain-
less contractions of the uterus, followed by regular periods of
relaxation, occur during pregnancy, and are owing to periodic
discharges of nerve force. They may be increased by manipu-
lation and often serve as a valuable means of diagnosis.
9. Kyestine in the Urine. This is a gelatino-albumin-
ous pellicle which forms on the surface of uvine of pregnant
women after it is allowed to stand a few hours. It is seldom |
seen before the second month and is most marked between the
third and seventh months.
These signs which we have thus far described are sometimes
known as sensible or positive signs, but there are others not
infrequent which are not peculiar to pregnancy as they may be
found in other states. If, however, they are noticed in healthy
married women, when there is no evident disease, they would
render it very probable that pregnancy had occurred. They have
hence been called rational or probable signs. They may be
trifling, or they may be distressing and severe, and they gradu-
ally merge into the diseases peculiar to pregnancy.
10. Morning Sickness. This is usually a feeling of
nausea or sinking at the epigastrium, dr vertigo, felt on rising
in the morning. It may beslight or goon to violent vomiting.
It usually occurs early in pregnancy and lasts three months. It
may occur in the evening, or it may be absent altogether.
11. Salivation or increased flow of saliva is a common
indication in pregnancy.
Besi:
pruriti
It is
the disc
mal,
augmel
in dist
blood-v
the non
and th
Lie
sure U
uterus
are sv
sists 1
and ba
(0).
by acr
To
(c).
confi
it may
ne of
va and
eins of
on the
e pain-
iods of
eriodic
anipu-
bumin-
regnant
seldom |
een the
metimes
lers not
may be
healthy
y would
ey have
may be
' gradu.
ling of
n rising
miting.
hs. It
OBSTETRICS. 29 Pi
Besides these we may have frequent desire to micturate,
pruritis vulvae, nervous irritability, etc. ;
It is impossible to draw a iine between the rational signs and i
the disorders of pregnancy, between the normal and the abnor- + :
mal. Thus the simple nervousness of pregnancy may be so
augmented as to result in convulsions ; the nausea may result
in distressing and dangerous vomiting; the fullness of the
blood-vessels may lead to general plethora or local congestion ;
the normal merges into the abnormal ; the healthy into disease, A
and this brings us naturally to a consideration of :— i
II. THE DISORDERS OF PREGNANCY.
1. Local.—(a). @dema of Labia. This is caused by pres.
sure upon the veins, and especially if the pelvis is large, the
uterus sinking lower and pressing upon the veins. The labia
are swollen and there is stiffness in walking. Treatment con-
sists in rest in the recumbent position, attention to the bowels,
and bathing with warm water and acetate of lead lotion.
(6). Pruritus of Vulva. This is intollerable itching caused . ("*
by acrid discharges or uncleanliness, or by diabetes.
To be treated similarly to the last.
(c). Metritis. Is usually caused by cold or violence and is
confined to the muscular coat. The pain is severe, continuous,
and increased by pressure. It often gives rise to adhesion of
the placenta.
It is treated by hot fomentations with turpentine, by morphia
and rest.
2. Reflex.—(a). Newralgia.
nine.
(6). Salivation. When excessive, treated by atropia., Co” fir
(c). Vomiting. Often becomes distressing and in some cases
even dangerous. It is best treated first by simple remedies as
bismuth, oxalate of cerium, ingluvin, hydrocyanic acid. This
ea ee
MAB:
Treated by tonics and quin-
30 OBSTETRICS.
failing, chloral, or tincture of iodine in drop doses may succeed.
If not, paint the os with solution of cocaine 4 p. c., or with
nitrate of silver, or use the spinal ice bag. Failing with this
dilate the os with steel dilator, and in rare cases it may be
necessary to induce abortion.
(d), Constipation.
(e). Syncope.
(/). Insomnia.
3 Mechanical. Ventral hernia, prolapse of rectum and
piles, eneuresis and dysuria, cramps, varicose veins, anasarca,
and albumenuria.
Hygiene of Pregnancy. As the respiratory activity is
increased and more C O , eliminated, pure air is essential. |
Country air is better than town, and close confinement is to be
avoided. The diet should be nutritious and easily digested,
and a large appetite should be restrained.
The dress should be loose and easy, garters and tight corsets
should be avoided, but flannel drawers should be worn. Gentle
exercise should be encouraged, such as quiet walks and drives.
Special care should be taken to avoid over-exertion at the men-
strual periods. Railway journeys should be interdicted, and
the marital relations should be infrequent, as this in newly
married persons is a frequent cause of abortion. Frequent
bathing is beneficial as it relieves the kidneys of a portion of
their work. The genitals should be frequently washed.
_ The friends should be instructed to exercise forbearance and
gentleness on account of the increased irritability of pregnancy.
IV. ABNORMAL PREGNANCY.
1. Due to Peculiar Conditions of Uterus.—(a).
Double Uterus. There are various forms, such as uterus and
cervix double and vagina single ; uterus double and cervix and |
vagina single ; uterus double, cervix single and vagina double ;
or the u
forms pe
sides sir
sufficien
decidua
end of p
(b). J
nancy t
it becon
tion of |
a few m
sary to
2. L
ometret
chronic
This
before
ovum ;
or adhe
3. I
(a).
shape,
(0).
tuting
utering
(c).
hydrar
to defe
(d).
calcar¢
4.
its
cceed,
r with
h this
hay be
m and
asarca,
vity is
sential. .
s to be
gested,
corsets
Gentle
drives. |
16 men-
ed, and
newly
requent
rtion of
ice and
znancy.
.—(a).
us and |
7ix and
louble ; |
OBSTETRICS, 31
or the uterus, cervix and vagina double throughout. All these
forms permit of normal utero-gestation on either side or on both
sides simultaneously, provided each half of the genital canal be
sufficiently developed. If pregnancy occur on one side only, a
B decidua vera is developed on the other side and expelled at the
end of pregnancy.
(b). Displacements. During the first few months of preg-
nancy the uterus may be retroverted and this may go on until
it becomes incarcerated behind the sacrum, resulting in reten-
tion of urine or abortion. It should be replaced and held up for
a few months by a pessary or in some rare cases it may be neces-
sary to induce abortion. ;
2. Due to Peculiar Conditions of Decidua. End-
ometretis deciduae may be acute, resembling Asiatic cholera, or
chronic, and give rise to hydrorrhea gravidarum.
This may be the result of previous endometritis existing
before pregnancy ; the result of syphilis ; irritation of diseased
ovum ; or retention of a dead foetus. It may result in abortion
or adherent placenta.
3. Due to Peculiar Conditions of the Placenta.—
(a). Asto Form. Instead of being round it may be horse-shoe
shape, or like a battledore.
(b). As to Position. It may be attached over the os, consti-
tuting placenta preevia ; over the fallopian tubes ; or in extra-
uterine pregnancy at various points in the abdominal cavity.
(c). Asto Development. It may be abnormally large, due to
hydramnion or hyperplasia ; and if too small it may give rise
to defective development of the fcetus.
(d). As to its own Nutrition. It may have undergone fatty,
calcareous or pigmentary degeneration.
4. Due to Peculiar Conditions of the Amnion and
its Fluid.—(a). Hacess of Amniotic Fluid or Hydramnion.
32 OBSTETRICS.
Causes. Usually results on the foetal side from mechanical of the
disturbance of the placenta and umbilical circulation. the mc
Symptoms. It impedes locomotion and produces discomfort @ the vil
and pain from distension, The lungs and heart are pressed ™ cratior
upon causing dyspnoea and palpitation. There are also neu-@ disinte
ralgic pains and cedema of labia and legs. amnio'
It usually results in premature expulsion with slow and pro- It is
longed first stage and mal-presentations ; in precipitate second § matert
stage ; and inertia in the third stage, leading often to post- Syn
partum hemorrhage. enlarg
Diagnosis. It may be mistaken for twins, but the tenseness# dough
of the uterine and abdominal walls, the feebleness or absence § abnor
of foetal heart sounds, and the difficulty in perceiving the foetus sound:
on palpation will assist in distinguishing it. the si2
Treatment. The abdomen should be supported, and active Tre
exercise prevented. If symptoms should be urgent premature °@refu
labor should be induced. great
i‘ ° ° ° ° e t ts
(5). Defective Amount of Amniotic Fluid. This is apt to poe 1:
limit the movements of the fetus and so cause discomfort to the fin
mother. It isalso apt to cause abnormal foldings of the amnion d i ge
and adhesions between it and the foetus, which give rise to
various deformities, to intrauterine amputation, etc. | Vv.
5. Due to Peculiar Conditions of Cord. May have
twisting, knots, or coiling of the cord
6. Due to Peculiar Conditions of the Chorion.—
Hydatitiform Mole. Is produced by a proliferative degenera-
tion of the villi of the chorion, a hypertrophy of their investing
epithellum and connective tissue cells, which undergo mucoid
degeneration. This gives them the appearance of cysts with
translucent semi-fluid contents, varying in size from a millet
seed to that of a walnut, and forming in mass a growth which
may attain the size of a child’s head or even larger. The fluid™
OBSTETRICS. 33
hanical @ of the cysts is albuminous closely resembling liquor amnii. If
the mole is found, as it usually is, during the first month, while
omfort @ the villi are equally developed on its entire surface, the degen-
pressed @ cration will involve its whole surface. The foetus then dies,
so neu-@ disintegrates and may undergo complete absorption, leaving the
amniotic cavity empty.
nd pro- It is more frequent in multipara, probably owing to a morbid
second # maternal condition such as cancerous or syphilitic dyscrasia.
to post- Symptoms. Failure of correspondence between the uterine
enlargement and the computed period of utero-gestation ; the
enseness ™@ doughy feel of the uterus; the lower segment of the uterus is
absence @ abnormally tense; absence of ballottement and fetal cardiac
he foetus sounds ; the passage of cysts; abortion usually occurs before
the sixth month. acre” a ss
d active Treatment. If the diagnosis is doubtful, non-interferen. ‘ut
‘emature @ careful watching would be best, but if certain, there is always
great danger of hemorrhage and the sooner the uterine con-
tents are removed the better. The tampon and ergot should be
employed, and in some cases the os may be dilated and the
fingers used to scoop out the cysts. Bear in mind the great
danger of hemorrhage and meet it actively and promptly.
is apt to
ort to the &
e amnion
e rise to
V. PREMATURE EXPULSION OF THE OVUM.
lay have An interruption of pregnancy any time before the sixth
month is spoken of as an abortion or miscarriage, after that as ©
rion.—Y 2 premature delivery.
legenera- There is little hope of the foetus living before the end of the
investing twenty-eighth week, or seventh lunar month, or 196 days.
o mucoid Abortion is very frequent and is said to occur as often as one
sts with B to every 10 labors. The number of fetal lives lost is therefore
a millet # enormous. They occur more frequently in multipara, and many
th which j cases of early abortion are mistaken for dysmenorrhea and
The fluid unrecognised. Their influence on the future health of the
4
34 OBSTETRICS.
patient is important ; they are rarely fatal, but from loss of blood
often lead to great debility and are one of the most fruitful
sources of uterine disease, probably because the patient is more
careless during convalescence and thus involution of the uterus
is interfered with.
Up to the end of the third month the ovum is cast off in mass,
the decidua afterwards coming away in shreds or in one mein-
brane, After that, the placenta being formed, the amnion is
first ruptured, the foetus is expelled and the. membranes are
shed as in natural labor. Often, however, the placental adhe-
sions are firm and the secundines being retained give rise to hem-
orrhage or septic poisoning, so that abortion is more dangerous
than natural labor.
Causes. The premature expulsion of the ovum is affected by
contraction of the uterine fibres ; the causes of abortion therefore
are all those which produce this effect.
1. Maternal.—(a). Predisposing. Over-heated and _ill-
ventilated rooms ; over-fatigue and excessive indulgence in the
pleasures of society ; alcoholic indulgence ; over-frequent coitus ;
fevers; zymotic diseases ; bronchitis; pneumonia; syphilis ;
lead-poisoning ; in short, all those circumstances that increase
the susceptibility. or irritability of the cerebro-spinal nervous
system.
(6). Ho Anything that directly or, indirectly excites
the ut » contract and expel its contents, such as fright,
anxiety, sudden shock, over-suckling, excessive vomiting, falls,
accidents, presence of a fibroid tumor in the uterus, old peri-
toneal adhesions, and displacements of the uterus, especially
retroversion or flexion.
2. Foetal. Death of the foetus, which may occur from
effusions of blood into the structure of the placenta, from
degenerations of its structure, or from atrophy, rupture,
twisting or knotting of the cord. |
Sym
After
such as
mictur
dischar
a threa
amoun
three |
the co
vestige
among
abnorn
of thes
m cases, ¢
and th
the ret
cervix
This g
abortic
with ¢
freque
the wo
rarely
exhaug
no mo
abortic
Dia
descen
called
once @e
for tre
P. TO
— cated,
cages
* blood
ruitful
3 more
uterus
1 mass,
mein-
hion is
es are
1 adhe-
(0 hem-
gerous
ted by
erefore
nd ill-
in the
coitus ;
philis ;
nerease
lervous
excites
fright,
y, falls,
d peri-
vecially
r from
1, from
upture,
OBSTETRICS. 35
Symptoms.—The two symptoms are hemorrhage and pain.
After the third month there are often premonitory symptoms
such as fulness, and weight in the pelvis, sacral pains, frequent
micturition, periodic labor-like pains, and a mucous or watery
discharge. These symptoms, followed by hemorrhage, indicate
a threatened abortion, the hemorrhage and pain increasing in
amount until the ovum is finally expelled. During the first
three months, if the death of the fcetus has occurred before
the completion »f the abortion, it often happens that every
vestige of the e:ibryo may disappear and you cannot find it
among the clots or secundines. In cases where there are
abnormal adhesions to the walls of the uterus, retained portions
of the secundines may remain after theovum is expelled, In other
cases, especially after the third month, the membranes rupture
and the embryo escapes with the liquor amnii. While usually
the retained portions quickly follow, it often happens that the
cervix contracts upon the contents and a period of rest follows,
This gives rise to what is commonly known as an incomplete
abortion. The hemorrhage may cease for a time, and then recur
with expulsive pains and force out the contents; or more
frequently there is putrid decomposition of tue retained portions,
the woman being thus exposed to septiceemia which, although
rarely fatal, gives rise to continuous fever, recurrent and
exhaustive hemorrhages or perimetritis. There is, perhaps,
no more fruitful source of uterine disease than a mis-managed
abortion.
Diagnosis. Hemorrhage, pain, dilatation of cervix, and
descent of the ovum, are sure signs of an abortion. When
called to a case of hemorrhage occurring during pregnancy, at
once examine the clots, even breaking them up under water,
for traces of the ovum.
Prognosis. “All cases of spontaneous abortion, if uncompli-
= cated, are, under proper treatment, devoid of danger, and fatal
cages are usually due to the ignorance, imprudence or wilfulness
36 OBSTETRICS
of the patient, or else to malpractice on the part of the
physician.
Treatment.—1. The Prevention of Habitual Abor-
tion. If it is due to syphilis, mercury or potass. iodid. are
indicated. If to retroflexion, use a pessary after replacing the
uterus ; this should always be removed after the third month.
In the newly married, if «bortion accidentally occurs, it fre-
quently recurs, being kept up by a morbid condition of the endo-
metrium used by the shortness of the interval between the
+ ~ggnancies, which does not allow the restoravion of the mucous |
membrane to a normal condition. A six weeks rest from coitus
will often cure such cases. In many cases of so-called habitual
abortion, fluid extract of viburnum prunifolium (black haw) in
dr. ss—i doses 4 times a day is very beneficial.
2. The Arrest of Threatened Abortion. This may
be affected where the death of the ovum has not taken place, and
where the hem rrhage arises from a slight detachment only of
the decidua or placenta.
Pain in the hack during pregnancy should always be a warn-
ing to rest. If ever so slight a hemorrhage should occur the
patient should lie down and keep perfectly still on her back.
Restlessness, pain and anxiety should be allayed by a full dose
of opium or a hypodermic of morphia. Then the black haw may
~~
be given and the patient should be kept in bed a full week after |
the final disappearance of all threatening symptoms.
3. The Management of Ixevitable Abortion,—
(a.) Where the Sac is not Ruptured. In these cases the
hemorrhage is rarely profuse. The ovum is forced into the
cervix by the uterine contractions and acts as a plug, the effused :
blood-coagulating between the ovum and the uterine wall.
In such a case, interference with the finger or tampon is |
unner
the p
hemo
then |
(d).
escap'
The
and t
the la
finger
pressi
with |
is not
prope
4.
patie1
comp
of the
Abor-
id. are
ing the
onth.
, it fre-
e endo-
een the
mucous
coitus
abitual
haw) in
his may
ace, and
only of
@ warn-
secur the
ar back.
full dose
law may
ek after
tion,—
ases the
into the
2 effused |
ll.
npon is |
OBSTETRICS. 37
unnecessary and does harm, unless you are at a distance from
the patient and fear to leave her on account of the dread of
hemorrhage coming on, or if it is long retained in the cervix ;
then you may dilate with the finger and hasten its exit.
(b). Where the Suc is Ruptured. Here the liquor amnii
escapes and. removal of pressure allows profuse hemorrhage.
The indication is t+ check hemorrhage and empty the uterus,
and the most effectual method to stop the former is to further
the lucter. If possible, remove the ovum by introducing the
finger, sweep the cavity of the uterus and withdraw its contents,
pressing on the outside with the left hand. Then wash it out
with a stream of warin bichloride solution (1-5,000). If the os
is not sufficiently dilated use a steel dilator, which can only be
properly done with a speculum.
4. The Management of Neglected Abortion. Ifa
patient comes to you two or three weeks after the supposed
completion of an abortion, with-a history of recurrent hemorr-
hages, you may be sure the ovum is there yet and the fetid dis-
charge and absorption of septic matter may lead to chills, fever,
and uterine or perimetric inflammation. In such cases the
hemorrhage, septicemia or perimetritis may terminate fatally.
You should at once empty the uterus and wash it out, and
in some cases it may be necessary to use a dull wire curette.
5. Management of Premature Labors. Here the
tampon may be usually discarded, and after rupture of the
membranes and expulsion of the foetus, hemorrhage may be con-
trolled by grasping the fundus and compressing the uterine walls.
You may introduce the fingers and remove the placenta assisted
by compression with the left hand.
In any of these manipulations the physician’s hands should be
scrupulously clean and then washed in bichloride solution
(1-1,000) and smeared with carbolized vaseline or salicylic
cream (vaseline 8 parts, acid salicyl. 1 part).
38 OBSTETRICS.
VI. EXTRAUTERINE PREGNANC™” OR ECTO- surrowl
PIC GESTATION. with tl
As the spermatozoa travel along the fallopian tube towards tines, 1
the ovary to meet the ovum, the latter after fecundation may Syn
be arrested and undergo development at some point outside of resemb
the uterus, and so we may have tubal, ovarian, or abdominal ceases.
pregnancy. in the
1. Tubal Pregnancy. This is the most frequent of the conver
three varieties. Then t
Causes. Catarrhal affections of the tube attended with loss like 1]
of ciliated epithelium ; dilatation of the tube ; anything which of por
causes obstruction, such as flexions, constrictions, presence of are th
polypi, ete. languc
As the ovum developes, the mucous membrane of the tube pull
thickens like the decidua and receives the club-shaped extremi- Ter
ties of the villi; a decidua reflexa is rare; the placenta is the ra
purely a foetal organ. As the ovum developes, the tube bonus
stretches. If allowed to progress, at any early period, usually foots
within the first three months, rupture of the sac occurs at the ruptut
point of least resistance and usually at the site of the placenta, pc
death occurring from hemorrhage or acute peritonitis. So the
Tubal pregnancy has been produced artificially in a bitch by 1.
exposing and ligating the fallopian tube. te "
2. Ovarian Pregnancy. Cases are on record where hanna
fecundation and development take place in the Graaffian follicle, 3
the walls of which, together with the ovarian stroma, furnishing ihe -
a membranous envelope like an ovarian cyst. 2
Rupture of the sac usually occurs within three or four pe
months. tala
3. Abdominal Pregnancy. In those rare cases where fostiia
the ovum |. ; been fecundated and dropped into the abdominal. of the
cavity, whenever the ovum comes into contact with the Di
peritoneum, a connective tissue proliferation is set ‘up which presen
TO-
wards
may
ide of
minal
f the
h loss
which
nee of
e tube
tremi-
nta is
tube
isually
at the
centa,
ich by
where
llicle,
ishing
- four
where
minal:
1 the
which
OBSTETRICS. 39
surrounds it with a vascular sac. The walls of this keep pace
with the growth of the ovum, and form adhesions to the intes-
tines, mesentery and omentum.
Symptoms of Ketrauterine Pregnancy. The earlier stages
resemble those of the intrauterine form. Menstruation usually
ceases. Up to a certain point the hypertrophic changes occur
in the uterus in the same manner, the mucous membrane being
converte. into a decidua and a mucous plug fills the cervix.
Then there are . .voxysmal pains in the sac and uterine pains
like those of labor which are often followed by the expulsion
of portions of decidua. When rupture occurs the symptoms
are those of internal hemorrhage, and shock, viz.:—yawning,
languor, pallor, fainting, clammy perspiration, rapid feeble
pulse, intermittent vomiting, collapse and acute anemia.
Termination. Although the usual ending of these cases is
the rupture of the sac causing death from hemorrhage - or peri-
tonitis, sometimes they terminate in recovery. Thus a dead
fetus may be retained for years, or when it dies previous to
rupture the ovum may degenerate into a mole, or the fetus
may undergo mumification and be converted into a lithopeedion.
So that we may thus have :
1. The death of the foetus and its becoming encysted in its
own membranes.
2. The rupture of the sac, and the death of the mother from
hemorrhage, shock or inflammation.
3. The rupture of the sac and the encysting of the foetus in
the cavity of the abdomen.
4, The occurrence of inflammation and abscess which may
destroy the patient, or result in w fistulous communication
between the sac and intestines or bladder, through which the
foetus may be evacuated in pieces, and subsequent obliteration
of the sac’ and complete recovery of the patient.
Diaynosis. The existence of the signs of pregnancy ; the
presence of a tunior external to the uterus ; the occurrence of
& .
4
40 OBSTETRICS.
paroxysmal pains; and the exclusion of an ovum from the
uterine cavity as determined by the sound.
Treatment. Varies with the stage of pregnancy and the
condition of the foetus.
1. Cases of Early Gestation. The indication is to
imitate nature, for spontaneous recovery commonly follows the
accidental death of the embryo. This may be accomplished in
various ways, such as puncturing the sac with a trocar or
Pacquelin’s cautery, to inject the sac with atropia or morphia ;
or, best of all, and the only method which should always be
resorted to in these cases, is by means of electricity. The
faradic current is applied for five to ten minutes daily for one or
two weeks Some recommend laparotomy. !
2. Cases of Advanced Gestation.—(a). Fatus Living.
In many cases extrauterine pregnancy escapes detection until
too late to employ a fceticidal method, and she may have gone
nearly or quite to her full time before the diagnosis is made.
Now although it may be very desirable to endeavor to save
both mother and child by laparotomy, the history of the
primary operation shows that there is only one chance in nine
of saving the mother, and one out of two in saving the child.
The elements of danger are the functionally active condition of
the placenta up to the moment of separating it from the foetus;
the abnormal characteristics of the placenta itself; the vas-
cularity of the cyst wall; and the peculiar position and non-
contractile vasis on which the placenta is attached.
(b). Foetus Dead. It is found by experience that if the
woman passes through the period of danger, viz., pseudo-labor,
without rupture of the sac, and the child dies, a longer delay of
ten weeks, on the average, will enable a secondary laparotomy
to be performed with a prospect of saving the woman in over
70 per cent of the cases.
The reason is that after foetal death the placental functions
cease, the vessels of the cord gradually close, as well as those |
directl:
blvod ;
coming
which
calibre
if the
s!owly
or nec
be left
above,
and th
Is t
extruc
sufferi
travai
Ts ¢
280 d
been
and 4
beyo
estab.
A
labor
strua
tion of
foetus ;
e@ vas-
d non-
if the
labor,
slay of
otomy
n Over
ctions
those |
OBSTETRICS. 4)
directly concerned in the oxygenating process of the child’s
blood ; the placenta undergoes a process of carnification, be-
coming more solid and tough and less vascular, and the vessels
which enter it from the mother are only of a number and
calibre sufficient to keep its tissue from decomposition. Hence,
if the foetus be now removed by laparotomy, exfoliation may
s:owly take place without opening any important blood-vessel
or necessarily favoring septic absorption. The placenta should
be left to come away spontaneously, the wound being closed
above, and left open below for the passage of the umbilical cord,
and the introduction of antiseptic injections.
C.—LABorR
Is the process by means of which the fully developed foetus is
extruded from the mother’s body, and as it is accompanied by
suffering and muscular exertion it has been termed labor,
travail or child-birth.
_.L THE DURATION OF PREGNANCY.
Is often a moral and a legal question. The average period is
280 days or 40 weeks or nine calendar months. Cases have
been prolonged to 10 months. The laws of France, Scotland
and Austria allow a possible limit of 300 days, and no case
beyond this from a single coitus has been scientifically
established.
A simplerule to determine the period of expected onset of
labor is to count back three calendar months fromthe last men-
strual period and add seven days.
Il. 1HE CAUSE OF THE ONSET OF LABOR.
During the first three months the growth of the uterus is
more rapid than that of the ovum, which is freely movable
within the uterine cavity except at its placental attachment.
In the fourth month the decidua reflexa becomes so far adherent
to the chorion that it can only be separated by some degree of
force, and the amnion is in contact with the chorion.
42 OBSTETRICS.
After the fourth month the amnion and chorion become
agglutinated, though even at the end of pregnancy they may be
with care separated from one another. After the fifth month
the agglutination of decidua vera and reflexa takes place. In
the last half of pregnancy the rapid development of the ovum
causes a corresponding expansion of the uterine cavity, the
uterine walls become thinned, so that by the end of gestation
they do not exceed two or three lines in thickness. The great
extension of the uterine cavity is not owing simply to over-
stretching, as is proved by the fact that the uterus toward the
close of gestation is increased nearly twenty fold in weight, and
by the histories of extrauterine gestation in which up to a cer-
tain period the uterus enlarges progressively in spite of the
absence of the ovum. The increase in weight is due to increase
in size and amount of muscular fibre cells, blood-vessels and
connective tissue.
At the same time that these changes in the uterus are being
completed there is increased irritability of the uterine tissue,
and finally a fatty degeneration takes place in the decidua ser-
otina which soon gives rise to separation of the membranes, the
contents of the uterus then acting as a foreign body, contrac-
tion takes place, and all being ready labor sets in. Another
element in the causation may be a periodicity inherent in some
way that we cannot yet explain in the nerve centres, like the
menstrual periodicity of 28 days.
Ill. SYMPTOMS OF LABOR.
Premonitory. Subsidence of the abdominal tumor takes place
a few hours or a few days before labor sets in, followed by a
sense of relief about the heart and lungs.
Then a relaxation of the soft parts: takes place, followed by
increased secretion, and a discharge of a small amount of
bloody mucus, known as a “show.” “False pains” are
frequent, and there is tenesmus of the rectum, increased fulness
of the mamme, and frequent micturition,
The |
and is ¢
For «
three 8s!
Ist |
intermi
or botl
good.”
greatly
On e
dant, t
soon th
As t
os is pl
As the
At the
of the
openin
waters
uterus
the cir
The
front ¢
retaing
cervix
canal.
stretc
know
2n
first s
stage,
frequeé
more
OBSTETRICS. 43
come The nervous system is often affected and she has tremors,
ay be and is anxious, depressed and fretful.
onth For clinical convenience actual labor has been divided into
In three stages :—
ovum § Ist Stage.— Dilatation of the Cervix. The pains become
» the intermittent and regular, and are felt in the back or abdomen
ation
great
or both, and the patient expresses a feeling that they “do no
good.” There is often nausea, vomiting, perspiration and
over-
d the
t, and
a cer-
f the
rease
and
greatly increased secretion.
On examination the secretion of the vagina is felt to be abun-
dant, the os is felt enlarging, the membranes protruding and
soon the presenting part can be felt.
As the pains increase in intensity and frequency the external
os is put upon the stretch, its edge becoming thin and sharp.
As the pain subsides the os relaxes and the membranes retreat.
At the same time the softening, relaxation and hypersecretion
of the soft parts increase. There are three elements in the
opening of the oc: 1. The mechanical stretching by the bag of
waters ; 2. Zhe contraction of the longitudinal fibres of the
uterus, which draw the cervix open, and 3. The relaxation of
the circular fibres.
being
issue,
a ser-
8, the
atrac-
lot her
ses The membranes then rupture and that part of the fluid in
ba the front of the presenting part escapes, while the rest may be
retained for a while. The head then presses down into the
cervix so that finally this and the vagina become one continuous
canal. Should the membranes be late in rupturing, and be
place stretched over the child’s head’ and face when born, this is
bya known. as a “ Caul.”
2nd Stage.—Lapulsion of the Child. The symptoms of the
ed by first stage gradually and insensibly glide into those of the second
nt of
stage, the contractions of the uterus rapidly becoming more
}) z
are frequent, returning every two or three minutes and becoming
Iness more pr'longed The uterine pains are now reinforced by
)
44 OBSTETRICS.
the abdominal muscles and the woman feels that they are
easier borne because she can help herself. The glottis serves as
asort of safety-valve action, for if the pains are weak she holds
‘her breath and bears down, and if they are excessive she cries
out, the glo'tis opens and the muscles do not have the same
purchase. The head now makes progress, the perineum bulges,
the labia gape, the head recedes during the interval and then
advances during the pain, the pressure on the rectum leads to
evacuation of the bowel, the perineum thus stretches over the
head and finally the head is born with great agony, a gush of
amniotic fluid and usually more or less laceration of the four-
chette, especially in primipara. There is usually an edematous
swelling on one or other parietal bone caused by pressure of
the circle of contact, which is known as the caput succedaneum.
The second stage is one of danger to mother and child ; to
the mother from all those accidents which may arise from dis-
turbance of the vascular and nervous systems, to irritation of
uterus, vagina and perineum, and most of those complications
which give rise to tedious and difficult or impracticable labors.
The child’s life may be endangered or destroyed by pressure
on its body or on the cord or placenta.
Srd Stage.—Hapulsion of Placenta. After the birth of
the child there is a short respite from pain, seldom longer than
10 or 15 minutes when the pain and bearing down recurs. <A
hard and tense tumor is felt through the abdomen, a finger in
the vagina feels the placenta at the os or in the vagina.
The placenta then usually presents its foetal surface or edge,
and is scon expelled with the membranes and more or less
blood.
IV. DURATION OF LABOR.
The average time for a primipara is 17 hours, for a multipara,
12 hours.
The first stage occupies 10 out of the 12 hours. Although
longer
mothe
this ti
and tl
distur
in con
t10.18
The
two |
streng
consti
Th
may t
from
hage.
this s
De
excit
often
ofte
anxi¢
weak
ther
full ;
refre
y are
ves as
holds
cries
same
ulges,
then
ads to
r the
ush of
four-
atous
ure of
neum.
Id; to
m dis-
tion of
cations
labors.
ressure
irth of
r than
5s A
ger in
r edge,
r less
ipara,
hough
OBSTETRICS. 45
longer and more tedious it is generally a safe stage for the
mother as well as the child, the mother not being usually at
this time liable to any of the accidental complications of labor,
and the child, if the membranes are unruptured, is very slightly
disturbed by the contractions of the uterus which have no effect
in compressing its tissues or injuring the attachments or func-
tiuas of the placenta.
The second stage is short compared with the first, occupying
two hours or less in a labor of 12 hours, depending on the
strength of the woman, the relaxation of her tissues, her age,
constitution, etc.
The third stage is short, usually only 10 or 15 minutes, but
may take half an hour. It is a stage of danger to the mother
from exhaustion, syncope, collapse, but especially from hemorr-
hage. Hysteria, puerperal convulsions, etc., may complicate
this stage.
Delivery being now accomplished the nervous and vascular
excitement rapidly disappear, and the mother feels weak, and
often faint and exhausted. She also feels cold and chilly and
often has a tremor or rigor, accompanied by depression and
anxiety of mind. The pulse becomes less frequent, small and
weak, hands and feet are often cold. In less than half an hour
there is a reaction, the surface becomes warmer and the pulse
full and natural, and she has a tendency to sleep which will
refresh her exhausted system.
V. THE BXPELLENT FORCES.
These are the essential and the accessory.
1. The Uterine Contractions (essential). That the
uterus is a contractile organ, is proved by its hardness and
rigidity and its alteration of form ; the sensations of twisting,
grinding and contraction ; the rigidity and alteration of the size
of the os ; the tension and protrusion of the membranes ; the
46 OBSTETRICS.
descent of the child; the pressure of the uterus on the hand
when introduced in version ; and by the rapid diminution and
obliteration of its cavity after evacuation of its contents.
Sometimes there is a general and uniform contraction of the
uterine muscular fibres by which the walls are rendered more
firm and tense, and its contents compressed. It is this tonic
rigidity or contraction of the uterus which compresses the
placenta after tle birth of the child, and when this is expelle:
the walls regularly condense and obliterate its cavity, so pre-
venting hemorrhage. This‘tonic contraction is usually painless
and is dependent entirely on the sympathetic nervous system.
Nervous Mechanism of Labor. The uterus is independent of .
direct volition, for its rythmic contractions go on in insensibility
from apoplexy, coma, anesthesia, etc. It is, however, under
the influence of emotions, as is seen when the pains leave by
the excitement of the physician’s presence, and come back when
he retires. It is in this manner that encouragement and hope
tend to help the progress of labor.
The causes of uterine contractions are :—
1. Periodic Centric Discharges of Energy. This is
seen during pregnancy in the alternate contraction and relaxa-
tion of the uterus, and in the contractions induced by ergot, by
excess of CO,, and zymotic diseases.
2. Reflex Stimulus. —(a) Through the Cerebro-spinal
Nerves. Examples of this are the contractions of the uterus
caused by suckling, cold to the body, the pressure of ‘the head
on the perineum, or the hand drawing back the perineum.
(6) Through the Sympathetic. Examples of this are whe.e a
dead ovum acts as a foreign body ; the beginning of ordinary
labor ; the use of the bougie to induce premature labor ; and
the dilating pressure of the bag of membranes or the foetal
head.
or
Ner
cord, or
there a
The
the cer
action
govern
cord fr
emotio
the ut
the sp
hence
Whe
more di
at first
vigorol
more O
In ©
twistin
The p:
a pain.
less a1
the elc
is dire
is espe
accour
uterus
that tl
the pe
finger.
dilatec
when
slow, |
hand
and
under
ve by
when
hope
‘his is
elaxa-
ot, by
spinal
iterus
| head
1.6 a
inary
OBSTETRICS, 47
Nerve Centres and Nerves. There are two centres in the
cord, one in the medulla and one in the lumbar region, and
there are also nerve centres situated in the uterus itself.
The centre in the medulla is for reflex stimuli, transmitted by
the cerebo-spinal nerves of the upper part of the body; from the
action of CO,, etc. The centre in the lumbar region immediately
governs the uterus. Stimuli are transmicced to it throu :h the
cord from the centre in the medulla, and also indirectly, as by
emotions, from the brain. The nerves carrying the stimuli from
the uterus are the sympathetic, but these have filaments from
the spinal cord through the lumbar and sacral nerves, and
hence the pains of labor.
When labor has fully commenced the uterus takes on a
more decided action ; the alternate contractions and relaxations
at first at long intervals become more and more rapid and
vigorous, and the intervals shorter. As these contractions are
more or less painful they are known as “ pains.”
In the first stage they are said to be cutting, gri ding,
twisting, but in the second stage pressing, bearing down, forcing.
The pain is experienced in every part of the uterus during
a pain, While the tonic contractions of the uterus are pain-
less and resemble those of the heart and other hollow viscera ;
the clonic contractions of labor are painful, because the uterus
is directly or indirectly connected with the spinal cord. This
is especially the case with the nerves of the cervix, thus
accounting for the greater sensibility of this portion of the
uterus. The first effect noticed of these clonic contractions is
that the os becomes rigid, then thinner and slightly open ; after
the pain it becomes soft, relaxed and yields more ‘readily to the
finger. This process goes on until in a few hours the os is
dilated, quicker in multipara than in primipara. As a rule
when the edges are thin and knife-like, the dilation will be
slow, epecially if. considerable density remains after the con-
Se ae
.— SS eee
48 OBSTETRICS,
traction has subsided. When the edges are thicker and softer
the os enlarges more rapidly.
Should the liquor amnii have escaped prematurely there is
often great retardation of the ~rocess, especially in primipara,
and it is know as a “ dry labor.”
Dilatation of the os is effected mostly by the longitudinal
fibres, by which the length of the uterus is shortened, there is
descent of the fundus and elevation of the os, and while the cir-
cular fibres of the os also contract, the action of the longitudinal
fibres is more powerful, so that the circular ones yield and the
os becomes dilated. Then the bag of waters, or the presenting
prt of the child, may be regarded as a mould upon which the
cervix expands. The membranes now usually rupture as the
os becomes completely dilated and the expulsive stage begins.
The descent and delivery of the child are accomplished by a
continuation and increase of the contractions of the longitudinal
and circular fibres of the uterus by which its cavity is dimin-
ished in every direction, and the child, greatly compressed, is
expelled through the only opening which exists at its inferior
extremity. The pains increase in severity as labor advances
owing to the fundamental law that the contractions of the
uterus are inversely as the size of the organ. -
The more the longitudinal and circular fibres are shortened,
the more efficient is their action. Hence, when the membranes
are ruptured and the liquor amnii evacuated the pains become |
more severe and prolonged. So, as the child descends they
increase, and finally the most severe contractions are felt at the
termination of labor, when the last portions of the infant escape
from the uterus. The placenta then being detached acts as a
foreign body and is expelled by the same forces.
2. Contractions of Abdominal Muscles and Dia-
phragm (accessory). Some have gone so far as to think that
the expulsive stage of labor is mainly performed by this means,
but th
in par
volun
or arr
The
as an
of th
can b
sneezi
Bef
strain
gainec
nervo
08 is ¢
pelvis
and o
the m
increa
conta
its fle
Th¢
tions
equal
to its
pressi
so thg
upon
forces
eum ¢
ment
expel
In
the w
ssedl, is
nferior
vances
of the
rtened,
branes
9ecome
3 they
at the
escape
gs as a
| Dia-
k that
means,
OBSTETRICS. 49
but the fact that labor may be completed under anesthesia, or
in paraplegia, and that in inertia of the uterus no amount of
voluntary action of the abdominal muscles will expel the child
or arrest hemorrhage is sufficient proof that it is not.
The action of these muscles is of great importance, however,
as an accessory force, for by their combined action the viscera
of the abdomen can be compressed and a particular direction
can be given to this force as required, just as in the acts of
sneezing, coughing, vomiting, and defecation.
Before the os is dilated there is not much disposition to
strain, and it ought not to be encouraged, for nothing can be
gained at this time, but it rather delays dilatation by increasing
nervous excitement and rigidity of the os. When, however, the
os is dilated, the sense of fulness, weight and pressure in the
pelvis causes a disposition to strain which cannot be resisted
and ought to be now indulged. The first efiect is rupture of
the membranes, then the tonic contractions of the uterus are
increased, so that the walls of the uterus are brought into close
contact with the Body of the child increasing at the same time
its flexion.
Their next effect is to strengthen and increase the contrac-
tions of the uterus by fixing and supporting it and making
equable pressure upon its surface, and giving a proper direction
to its axis. The uterus being fixed by its attachments and
pressing against the brim of the pelvis cannot descend lower,
so that the abdominal muscles act through its walls directly
upon the child forcing it downward through the pelvis. These
forces also facilitate the distension and elongation of the perin-
eum and enlargement of the vagina; they aid in the detach-
ment and expulsion of the placenta and clots, and finally in
expelling them from the vagina. |
In breech cases it is this force which expels the head and
the woman can thus effectually help herself.
OBSTETRICS.
50
VI. MECHANISM OF LABOR.
This comprehends the movements of adjustment by which the
foetus accommodates itself to the dimensions of the bony pelvis,
and to the variations in the direction of the parturient canal.
To thoroughly understand the process it will be necessary to
study the pelvis and the foetal head :—
1. The Female Pelvis. The bony pelvis is formed by
the union of the sacrum, coccyx and the two ossa innominata.
The savrum is shaped like a wedge and consists of a vertebra]
portion with twoale or wings. In early life it consists of five
vertebrae but afterwards they amalgamate into one single piece.
Its base articulates with the last lumbar vertebra with which
it forms a projecting angle known as the promontory of the
sacrum. The sacrum measures 4} in. long by 44 in. wide, and
has two curves, a lateral and a longitudinal.
The coccyx is composed of four rudimentary vertebre. It is
attached by a hinge joint to the sacrum, and is pushed back
during defecation and child birth. When gnchylosed it is a
hindrance to labor.
The ossa innominata up to the age of puberty cunsist of three
bones, the ilium, ischium, and pubis, and although they are
afterwards amalgamated, they still retain the same names.
The articulations are the symphysis pubis, and the sacro-iliac
synchondroses. During pregnancy the fibres of the pubic fibro-
cartilage become infiltrated with serum and the ligaments elong-
ate, so that at full time the distance between the pubic bones is
doubled, and, at the same time, a slight degree of mobility exists
atthe sacro-iliac joint. This arrangement facilitates labor;
thus at the beginning of labor as the head enters the brim the
woman naturally chooses to sit up, to walk about, or if in bed
to recline with the legs extended, positions which favor the
rotation backward of the upper portion of the sacrum, and con-
sequently increase of the antero-posterior diameter of the superior
strait
pelvis
body
musc!
pressi
the s¢
the p
Th
obtur.
ments
formi.
The
two p
basin-
EXCH f
Tn |
sions
axes,
Pla
simpl
ness,
the u
cav it
The
bound
with
prom¢
meas
diame
te the
Th
iliac ¢
h the
elvis,
anal.
ry to
d by
lata.
bra]
f five
piece.
which
f the
3, and
It is
back
tis a
three
y are
o-iliac
fibro-
plong-
pnes is
exists
labor;
m the
n bed
or the
d con-
perior
OBSTETRICS. 51
strait. As the head, however, descends to the floor of the
pelvis, the patient instinctively draws up her knees, throws the
body forward, and during a pain contracts the abdominal
muscles. In this way she succeeds in tilting up the pubis, in
pressing the promontory forwards, and in rotating the point of
the sacrum backward, thus increasing the conjugate diameter at
the pelvic outlet.
The ligaments are the obturator membrane closing che
obturator foramen, and the greater or lesser sacro-sciatic liga-
ments which convert the notches into ‘oramina and assist ir.
forming the inclined planes of the pelvis.
The complete pelvis is divided by the ileo-pectineal line into
two parts, the false above, and the true below. ‘The latter is a
basin-like cavity, closed in by soft parts below, and called the
excas ation. .
Tn order to understand the changes in the shape and dimen-
sions of this bony canal it is usual to describe certain planes and
axes.
Planes and Axes of the Pelvis. By a plane is meant
simply a superficial surface without reference to depth or thick-
ness. The upper and lower openings are termed respectively
the upper and lower straits, while the space between is the
cavity of the pelvis.
The plane of the superior strait or brim of the pelvis is
bounded by the linea pectin:a and has an elliptical contour
with a depression behind produced by the projection of the
promontory of the sacrum. Its dimensions are determined by
measuring its diameters. The antero-posterior or conjugate
diameter extends from the upper border of the symphysis pubis
te the promontory, and meas™™ss 44 inches.
The oblique diameter extends, the right from the right sacro-
iliag synchondrosis forward, the left from the left sacro-iliac
52 OBSTETRICS,
synchondrosis forward to the acetabulum, and measures 5
inches. '
The transverse diameter is the widest distance between the
ilia, and measures 54 inches.
The axis of the superior strait is a line perpendicular to the
centre of its plane, and extends from the umbilicus to the
coccyXx.
The plane of the inferior strait, or the outlet, is bounded by
the subpubic ligament, the pubic rami, the rami and tuberosities
of the ischia, the sciatic ligaments and the coccyx.
The conjugate diameter of the outlet extends from the lower
borde: of the symphysis to the extremity of the coccyx and
measures 3} inches, but when the coccyx is pushed backward
it measures 44 inches.
The oblique diameters of the outlet are unimportant owing to
the elasticity of the sciatic ligaments,
The transverse diameters of the outlet extend between the
inner borders of the tuberosities, and measure 4 inches,
The axis of the outlet, when the coccyx is undisturbed,
touches the promontory; if it is pushed backward it touches the
lower border of the first sacral vertebra.
The pelvic cavity has an irregular cylindrical shape, its
diameters being increased by the concavity of the sacrum, its
anterior depth being 14 inches, its posterior being 4} toe 5
inches.
The axis of the pelvic cavity may be represented by a line
drawn perpendicular to a series of intersecting planes radiating
from the symphysis as a centre, the upper being somewhat
parallel to the plane of the superior strait, and the lower some-
what parallel to the plane of the outlet. The axis resembles an
ellipse.
The Inclined Planes. ‘The ischiatic spines divide the pelvic
cavit:
sectic
ward:
inclin
in th
plane
and i
of no
Th
from
of an
4,90 |
In
‘ dimin
it bec
filled
muse
Th
whic
ani a
ineal
and
ye, its
1m, its
te 5
a line
liating
ewhat
- gome-
bles an
pelvic
OBSTETRICS. 53
cavity into two unequal sections; in the anterior and larger
section the lateral walls slope downwards, inwards, and for-
wards towards the pubic arch, and are know as the anterior
inclined planes upon which rotation of the occiput takes place
in the mechanism of normal labor. The posterior inclined
planes are smaller and slope downwards, inwards and backwards,
and it is upon these that the sinciput rotates in the mechanism
of normal labor.
The diagonal conjugate or sacro-sub-pubic diameter reaches
from the pubic arch to the promontory of the sacrum and is 3
of an inch longer than the true conjugate and hence it measures
4.90 inches.
Influence of the Soft Parts. The psoas and iJiacus muscles
‘ diminish the transverse diameter nearly half an inch, so that
it becomes the same as the ovlique. The sciatic notches are
filled by the pyramidelis and the tendon of the obturator
~ Jat RAG
muscle. ty s
The outlet of the pelvis is closed by a succession of layers
which form the perineal or pelvic floor and include the levator
ani and coccygeus muscle, the pelvic fascia, the superficial per-
ineal muscles, including the constrictor vagine, ischio-cavernosi,
and transversus perinei.
By the bulging of the perineum during labor, both the length
and degree of curvature of the pelvic canal are increased, the
soft parts posterior to the vulva forming a gutter-like exten-
sion, the axis of which is continuous with that of the pelvis.
2. The Foetal Head. This part presents the greatest
mechanical difficulty to the passage of the child. The vault
or compressible portion is composed of the frontal and parietal
bones and the squamous portion of the temporal, and occipital.
The posterior part of this is spoken of as the occiput while the
opposite extremity of the ellipse is called the s:nciput. The
base or incompressible portion is formed by the union of the
a: a
<r es
ee oe
SS SSS
ee
oS Ne ee
54 OBSTETRICS.
ethmoid, sphenoid, petrous portion of the temporal, and the
basilar portion of the occipital.
The Sutures and Fontanelles. The flat bones of the vault
are held loosely in position by periosteum and dura mater,
The sutures are the frontal, coronal, sagittal, and lambdoidal.
The anterior fontanelle or bregma is rhomboidal, the pos-
terior fontanelle is smaller and triangular.
The Diameters of the Head.
1. Antero-posterior :
a. Occipito-mental............ 54 inches
b. Occipito-frontal............. 4,“
c. Sub-occipito-bregmatic........ 3% “
2. Transverse :
.a. Bi-parietal...........0. 06% 3% inches
b. Bi-temporal................. oi.
Ch MASTOID, oo dace EF es 3 a
3. Vertical :
a. Fronto-mental.............. 3} inches
b. Cervico-bregmatic........... 3g.
The articulation of the head with the spinal column at a
point nearer the occiput than the sinciput. is of importance in
the mechanism of labor. It converts the head into a lever,
consisting of two unequal portions. As the child’s head passes
through the pelvis the resistance to i's passage causes flexion of
the chin upon the thorax.
VII. EUTOCIA OR NORMAL LABOR...
Vertex presentations alone are to be regarded as normal, as
they only realize the ...echanical conditions compatible with the
highest degree of safety to both mother and child. Perfect
acquaintance with all the details of thi. natural process is neces-
sary to a scientific knowledge of midwifery. ‘The physician
Th
anter
terio1
Th
descr
rotati
Le
cribij
differ
1si
left a
able
dia
and
redu¢
child
cave
the
ault
ater,
al.
pos-
at a
ice in
lever,
ASSES
ion of
al, as
h the
erfect
heces -
sician
OBSTETRICS. 55
who is well acquainted with the mechanism of labor, can by
various measures facilitate such changes as to shorten the
progress of labor and thus diminish the anxieties, sufferings and
dangers of the lying-in woman, and also greatly increase the
chances for the safety of her child.
By presentation is meant that portion of the foetal ellipse
which is felt toward the centre of the canal of the pelvis or
vagina.
By position is meant the relation of the presenting part to
the pelvic cavity.
There are four positions of the vertex. 1. Left occipito-
anterior. 2. Right occipito-anterior. 3. Right occipito-pos-
terior, and 4. Left occipito-posterior.
The mechanism of labor in vertex presentations is usually
described as consisting of several acts, viz: Descent, flexion,
rotation, extension, restitution and expulsion of the trunk.
Let us now study the mechanism of the first position, des-
cribing each act, and then we can see how the other positions
differ afterwards.
lst Position, Left Occipito-anterior, L. O. A. Occiput is to
left acetabulum. ‘This is the most frequent and the most favor-
able of all the positions of the vertex. The reason the long
diameter of the head generally enters the pelvis in the oblique
and not in the transverse diameter, is that the psoas and iliacus
reduce the latter to the same length as the former, and as the
child lies usually with its back forward to accommodate its con-
cave anterior surface to the convexity of the mother’s spine, so
the head more naturally then enters the oblique than by
twisting as it would if it engaged in the transverse diam-
eter. Then as the left oblique diameter is partially occu-
pied by the rectum and sigmoid flexure of the colon ; as the
pregnant uterus generally has a natural obliquity to the right
56 OBSTETRICS.
and is rotated on its axis so that its front looks towards the
right and its left is foremost and most dependent, the foetus is
most readily accommodated to the shape of the uterus when its
antero-posterior nearly corresponds with the transverse or great-
est diameter of the uterine cavity, and hence the first position
is most common.
On a ee the finger comes in contact with the pos-
t \-or angle of the parietal bone, and detects the right
branch of the lambdaidal structure. Following this downwards
and backwards you come to the overlapping edges of the pos-
terior fontanelle.
1, Descent and Flexion. These movements are usually
associated, descent taking place owing to the essential and
accessory forces, flexion being due to the vertex meeting some
resistance in the parturient canal, the force transmitted through
the spine causing the descent of the occiput and flexion of the
head on the chest. The head enters the pelvis in the axis of
the brim, with the biparietal diameter parallel with the plane
of the superior strait. It is a. passive movement, and takes
place as soon as the occiput has met with sufficient resistance
to arrest its further progress, the end being the substitution of
a shorter diameter for a previously longer one. Thus the
average length of the sub-occipito-bregmatic diameter of the
flexed head, 3% in, is #in. less than the occipito-frontal or
maximum diameter of the head when midway between extension
and flexion.
Another cause of flexion, independent of the bony pressure,
depends upon the relation between the shape of the head’ and
the pressure exercised upon it at the girdle of contact either
with the os or the imperfectly expanded soft parts, the propel-
ling force being the general fluid pressure transmitted to the
foetus through the liquor amnii. The head forms an unequal
wedge, the slope at the occipital end being steeper than at the
impings
pubic a
frontal
in flex:
2. I
‘incline
the pu
‘im ping
wards,
The ob
diamet
3. ‘FE
against
upon t
thorax.
sacrum
coccyx
vulva, ¢
the per
head e
4.
the pe
quarter
same pd
pelvis.
5. H
and the
2nd
occiput
the left
The
except
the
1s 18
n its
reat-
tion
pos-
‘ight
ards
pos-
lally
and
Ome
ough
’ the
is of
lane
wakes
ance
on. of
the
f the
al or
nsion
sure,
» and
ither
‘opel-
o the
equal
t the
OBSTETRICS. 57
frontal, so that the force and resistance just explained result
in flexion of the head upon the chest.
2. Rotation. The occiput now impinges on the left anterior
‘inclined plane, gliding downwards, inwards, and forwards, under
the pubic arch where it becomes fixed, while the sinciput
impinges on the right posterior inclined plane, gliding down-
‘wards, inwards, and backwards into the hollow of the sacrum.
The object of rotation is to change the head from the oblique
diameter of the brim to the conjugate diameter of the outlet.
3. Extension. The lower part of the occiput resting
against the under surface of the pubis, the propulsive force acts
upon the sinciput causing separation of the chin from the
thorax. As soon as the forehead has swept the hollow of the
sacrum and passes the apex of the sacrum, the recoil of the
coccyx and elastic perineum drives the head forward to the
vulva, and as the biparietal diameter passes the vaginal orifice
the perineum rapidly retracts, gliding over the face and the
head emerges.
4. Restitution. The head now, not being supported by
the perineum, falls toward the anal orifice, and performs a
quarter rotation, the occiput turning toward the left thigh, the
same position it occupied at the brim before it engaged in the
pelvis. This movement is due to the rotation of the shoulders.
_ 5. Expulsion of the Trunk. The right shoulder
impinges on the right anterior inclined plane, fixes under the
‘pubic arch, the left shoulder sweeps the hollow of the sacrum
and the body emerges. ,
2nd Position, Right Occipito-anterior, &. O. A. Here the
occiput is towards the right acetabulum, and the head occupies
the left oblique diameter.
The mechanism is precisely the same as in the first position
except that the occiput impinges on the right anterior inclined
=e ae See
a ee a EY
a
ioe
aie SESS ee ee 7
Popeye 2a et AMS CPR MG z
Ra teas ca
Soir eae ae
ee SS ~
; - -
58 OBSTETRICS.
plane, and the left shoulder on the left: anterior inclined plane increa:
while the right shoulder sweeps the hollow of the sacrum. owing
3rd Position, Right Occipito-posterior, Rk. O. P. Here the Cases
oceiput is towards the right sacro-iliac synchondrosis, and the perine
head occupies the right oblique diameter. This is the reverse The
of the first position. incline
The chief cause of occipito-posterior positions is a partial oe
extension of the head during the early stages of labor, the fore- 4th
| head being thrown anteriorly in accordance with the law that put is
| the most dependent portion of the presenting part is moved to pies tl
_ the front. owing
Now one of two things will occur: either it will be converted the rec
into the 2nd position, or will become persistent 3rd It m
1. Itmay be Converted into a 2nd Position. One ne '
iat Oo
cause is the prominence of the promontory of the sacrum which
has a tendency to throw the head on to the anterior inclined
plane.
Wer
Another cause is the spine of the ischium and the greater te iii
length of the anterior than the posterior inclined plane. Hence eee
when the head descends in the 3rd position, if the occiput aubciibe
strikes on the spine of the ischium or extreme boundary of the B oacog ;
anterior inclined plane, it will be reflected forwards, and imping- J og, pre
ing on the anterior inclined plane be converted into the 2nd rantae
position. forest,
?
If, however, the point of the occiput should strike posteriorly § forth
restore
speedil
somew
the diff
as the i
The
the ph
to the spine of the ischium, it will be reflected backward into
the hollow of the sacrum, and we have :—
2. Persistent 3rd Position. Here descent and flexion
take place just as in the 2nd position, but there is no extension
movement, extreme flexion taking its place. Restitution
occurs as in the 2nd position. The difficulties arise from
loss of power from the peculiar position of the child, from the §
plane
re the
d the
everse
partial
e fore-
vy that
ved to
verted
One
. which
clined
preater
Hence
occiput
of the
mping-
1e 2nd
eriorly §
rd into
flexion
tension
itution
e from
‘om the 8
OBSTETRICS. 59
increase.l resistance met with by the head during its descent,
owing to extreme flexion instead of extension. Hence these
cases are tedious and there is more danger of rupturing the
perineum. ree
The left shoulder usually impinges on the Wairierior
inclined plane while the right sweeps the hollow of the
sacrum.
4th Position, Left Occipito-posterior, L.O. P. Here the ocei-
put is to the left sacro-iliac synchondrosis, and the head occu-
pies the left oblique diameter. This position is less frequent
owing to the presence of the sigmoid flexure of the colon and
the rectum.
It may be converted into the 1st position or become persis-
tent 4th, the cause and mechanism being precisely similar to
that of 3rd position, but reversing the planes.
MANAGEMENT OF LABOR.
Were labor always the natural physiological process it ought
to be, no treatment whatever would be demanded. Thus
throughout the world thousands of children are daily born with-
out the least supervision by an instructed. physician, in many
cases in secresy and retirement, and often delivery is safely
effected even in opposition to superstitious practices and igno-
rant interference. The savage woman retires, it may be to the
forest, and secluded even from her female companions brings
forth her child, and perhaps in a few hours is sufficiently
restored to attend to her own and her infant’s necessities, and
speedily returns to her usual laborious occupation. While
somewhat similar cases rarely occur in civilized society, stil]
the difficulties and dangers of labor are exceedingly augmented
as the indulgences and luxuries of life are wultiplied.
The diminution of physical power, the nervous excitability,
the physical alterations from tight lacing, and the mental and
= oo
[SS Se Se
ee a Se ee ee ee oe
Sar
a
By
sf
,
60 OBSTETRICS.
moral development cf the educated lady all predispose to vari-
ous complications, while at the same time the natural processes
are more imperfectly and less efficiently executed.
Now while meddlesome midwifery is bad, it is necessary to
know when to interfere as well as when to abstain. It is therefore
your business to carefully watch the whole process of labor, to
ascertain whether it is perfectly regular, and to detect the least
deviation from the natural process, and thus you may often
render timely assistance. You should sustain the mind and
spirits of the mother and explain to her what sensations she
should encourage and what she should resist, and in what
manner she can most effectually promote her safe delivery.
Preparatory Treatment. When called to a case you should
go at once, for it is better to be a few hours too soon than one
minute too late. If it is in the country or any distance from
your office go prepared for every emergency, and take your
pocket case, enema syringe, hypodermic syringe, the very best
fluid extract of ergot, chloroform, perchloride of iron, chloral,
your obstetric forceps, and a solution of bichloride of mercury
in alcohol (dr. 1—oz. 1).
At the house see that they have brandy, and plenty of hot
See yourself that the bed is properly made
After the patient has become at
ease with you, suggest an examination to “ see if all is right.”
By the finger in the vagina you will recognise not only the
presentation but the condition of the vulva and perineum, the
state of the rectum and bladder, the length of the vagina, the
and cold water.
and the patient arranged.
degree of dilatation and softening of the cervix, the amount of
cervical and vaginal secretion, the hardness of the child’s head,
and if the membranes are not ruptured the quantity of the
amniotic fluid.
It is best to examine the patient while lying on her left side,
but in some cases she may best be upon her back, and you
should
see the
You
the abc
auseullt
Whi
such as
nancy,
5 now uy
and sit
as to d
Befo
should
bichlor’
Duri
too frec
on,
Caut
from t
be full
walk al
drinks
rupture
since t
You
is unsd
or back
advante
tions,
vari-
cesses
uy to
refore
or, to
> least
often
1d and
is she
what
y.
should
nm one
e from
» your
‘y best
hloral,
ercury
of hot
made
pme at
right.”
ily the
m, the
na, the
ount of
s head,
of the
ft side,
nd you
OBSTETRICS, 61
should wait for a pain, but afterwards keep the finger theve to
see the effect during the interval.
You should*also try to map out the position of the foetus on
the abdomen by palpation and if the foetal movements are absent
auscultate.
While this is going on enquire into the history of the case,
such as the length of previous labors, her health during preg-
nancy, the number of previous pregnancies and whether she is
now up to full time, when the pains began, as to their frequency
and situxtion and if the membranes have ruptured. If asked
as to duration of labor be guarded and possibly ambiguous,
MANAGEMENT OF FIRST STAGE.
Before making any vaginal examination the hands and nails
should be scrupulously clean, and then washed in a solution of
bichloride (1 to 1000), and the finger smeared with vaseline.
During the first stage, you should make occasional, but not
too frequent, vaginal examinations to see if dilatation is going
on.
Caution her to pass urine frequently and occasionally retire
from the room to allow her to doso. If the rectum is felt to
be full use an enema. She should be encouraged to sit up and
walk about, but never to bear down during this stage. Warm
drinks may be employed. When the os is dilated you may
rupture the membranes if that has not occurred spontaneously,
since they have finished their work and now only retard labor.
MANAGEMENT OF SECOND STAGE.
You should now insist on the recumbent posture, as the erect
is unsafe for both mother and child. The position on the side
or back is a matter of indifference, but may be varied with
advantage, and now you should make more frequent examina-
tions. So long as the advance is regular do not interfere, but
et
~~ a a ee
OBSTETRICS,
should.the pains slacken you should not let the duration of the
second stage exceed the physiological limits. A very rapid
second stage is not natural as it endangers the integrity of the
vagina and perineum and predisposes to postpartum hemorrhage.
Every adjuvant should be used during this stage to assist
the process, such as change of posture, pressure upon the abdo-
men, drawing up the knees, pressing on a foot board, holding
the hands or sheet. In occipito-posterior positions, failure of
rotation is always due to insufficient flexion, hence you should
try to promote this by pressing on the forehead by the fingers
during the pain, try to assist rotation, and during the interval
of a pain hook two fingers over the occiput and draw it down-
wards and forwards.
ATTENTION TO THE PERINEUM.
Direct pressure on the perineum should be avoided by trying
to check the two rapid advance of the head and by pressing the
head forward to the pubic arch so as to equalize pressure on
the ring of the vulval outlet, and by favoring the expulsion of
the head during the interval of a-pain.
If the pains are very severe at this time the woman should
be encouraged to cry out and not to bear down, and if these
means are not likely to avoid atear you should use chloroform.
In rare cases episiotomy may be resorted to.
When the head is born wipe the mucus from its mouth and
nose, and see that the cord if round its neck is untwisted. Sup-
port the child and lift it upwards, being careful not to hurry
matters as the shoulders often tear a perineum unscathed by
the head.
You should now give the mother a dose of ergot.
cord has ceased to pulsate tie it about two inches from the
navel and again an inch further off for the sake of cleanliness,
When the
cut it b
now at
uterus
that yo
go of tl
You
from 1&
on the «
your ob;
uterine
Shoul
method
apply at
the ute
grasp t
downwa
the place
This
hage, anc
dangers
It is v
see that
The c
ones sub
in maint
gestion,
abdomen
Use of
labor, an
hypertro
which leg
OBSTETRICS. 63 |
{
f the cut it between, and hand the child to the nurse. You should ‘
rapid now at once place your left hand upon the abdomen over the i):
f the uterus relieving the nurse who has attended to this all the time | |
hage. that you have been tying and cutting the cord, and never let | ‘
sli go of the uterus until the third stage has been fully completed. | lf
il MANAGEMENT OF THIRD STAGE. :
in Bi
re vy You should keep your left hand upon the uterus and wait I {
10uld from 15 to 20 minutes for a contraction, not making traction hi
ngers on the cord but simply holding it tense with your other hand, i
erval your object now being to guard against hemorrhage, to promote ‘
lown- uterine contractions and to secure the expulsion of the placenta. ;
Should the placenta not be expelled in 20 minutes, Crede’s |
method or a modification of it should be resorted to, viz:
apply at first light and then stronger friction to the fundus of
rying the uterus until an energetic contraction is obtained, then
g the grasp the uterus in the palm of the hand and by compressing it
ee downward in the axis of the uterus and repeating this process
Lh dae the placenta is eapressed from the uterus and vagina.
This method by maintaining contraction prevents hemorr-
hage, and by promoting speedy pa cad guards against the
dangers of retention.
a It is well to retain the hand on the uterus for a short time to
see that it contracts firmly and that clots are not retained.
The cloths with discharges are now removed and warm dry 4
and ones substituted, and a bandage is applied. A bandage assists a
Sup Fin maintaining uterine contraction, in preventing passive con- Ht
perry gestion, supporting the parts and preventing pendulous | |
ed by ;
abdomen.
en the § labor, and is safer at this time than any other owing to the
m the §{ hypertrophy of the heart and increased aortic blood pressure,
liness, § which lessens the danger of sudden anemia of the brain.
Use of Anesthetics. Chloroform is preferable to ether in | |
}
!
4 OBSTETRICS.
In ordinary labor, when called for, it need only be given
during the pain, unless some obstetric operation is undertaken,
and then the patient should be put thorougnly under it. If
the pains are weak or there is any tendency to hemorrhage
chloroform should be avoided.
After the patient has been bathed about the labia, a piece of
gsuze or clean rag soaked in bichloride sclution (1-2000) should |
be applied and over this a pad made of gauze filled with
absorbent cofton or tow. These pads are cheaper than napkins
and cleaner because they can be burned after being used for a
few hours, forra napkin can never be washed so as to be thor-
oughly aseptic.
VIII. DYSTOCIA OR EXTRAORDINARY LABOR.
1. From Imperfect Uterine Efforts.—(a). Irregular
Action. To understand how this impedes labor it is necessary
to bear in mind the principal features of normal labor, viz:
regular contractions of the uterus followed by relaxation and
distinct periods of repose ; stretching and thinning of the mus-
cular fibres of the lower part of the uterus and retraction of the
uterus above that point ; softening and dilatation of the cervix ;
fixat?on of the uterus in the axis of the pelvis and the addition
of the accessory to the essential forces.
in the first stage of labor the pains are most frequently |
defective from their short duration, or exhausting from being
too rapid. Premature rupture of the membranes and loss of
liquor amnii is apt to cause a “ dry labor.”
Treatment, Always try to iind the cause and then regulate
th» pains and resiore then to their normal character. * See
that the bladder and rectum are evacuated ; secure abdominal
support if there is faulty position of the uterus ; in hydiamnion
rupture the membranes ; if pains are exhausting use chloroform ;
if os is rigid the hot vaginal douche or chloral may assist ; qui-
nine in gr. v doses will often strengthen the pains.
In
irregt
have |
may |
causes
(6).
uterin
erful —
tissue
tion °
Tre
to eith
broken
then th
irritati
Duri
obstrue
ciple th
organ,
down.
the fore
Durit
_ cause o
The
by Dr. ¢
contract
intermis
become
Indicd
or linge
2. To
cncangel
accidentd
6
iven
‘ken,
melt
‘hage
ce of
hould
with
pkins
for a
thor-
OR.
ogular
essary
iy VIZ:
mn and
b mus-
of the
ervix ;
dition
wently &
being
loss of
wulate
. See
pminal
mnion
‘ qui-
bform ; F
OBSTETHICS. 65
In the second stage, if a deformed pelvis is not the cause of
irregular action, ergot or forceps may be indicated. You may
have spasm of the os around the neck or body of the child, and
may have to use forceps. In the third stage irregular action
causes hour-glass contraction.
(6). Inertia, Is a diminution or temporary suspension of
uterine action. It may arise from deficient nerve force ; pow-
erful emotions ; plethora; weakness of the uterine muscular
tissue ; exhausting disease ; constitutional debility ; malnutri-
tion’ plural births ; hydramnion, and fatigue. .
Treatment. During the first stage there is very little danger
to either mother or child especially if the membranes are not
broken. The bladder and rectum should be evacuated, and
then ths hot vaginal douche, gentle friction, hot drinks, digital
irritation of cervix and mental encouragement will all assist.
During the second stage the danger is to the child from
obstruction to delivery. Rupture the membranes on the prin-
ciple that uterine contractions are inversely as the size of the
organ. Change the posture and encourage the patient to bear
down. If this i« not enough give ergot, use electricity or apply
the forceps.
During the third stage inertia is most dangerous and is the
cause of post partum hemorrhage.
The use of Ergot. It was introduced into obstetric practice
by Dr. Stearns, in 1807. It excites very strong and powerful
contractions of the useras which are very persistent and the
intermissions are of comparatively short duration. The pains
become of a tonic rather than of a clonic character.
Indications. 1. To increase the uterine pains in protracted
or lingering iabors.
2. To hasten delivery when the ‘ife of the patient is
endangered by some a... ‘ming symptoms, such as convulsions,
accidental hemorrhage, ete.
8
66 OBSTETRICS,
3. To restrain uterine hemorrhage by causing firm contrac-
tion of the uterus.
Munde’s pill for use in some cases after delivery, consists of
ext. ergot gr. i, quinine gr. i, ext. nux. vom. gr. 4. Take one
three times a day.
Contraindications. 1. During the first death of labor.
2. Rarely, if ever, in primipara. Ma ZA eed
3. In mal-presentations, or mal-positions of the fete
4, In rigidity of the os, vagina, or perineum.
5. In disproportion between the head of the child and the
pelvis.
4 6. In abortions. i Hssrer 9 a tnasrmred at: Leeaenlee
2. From Impeded Uterine Efforts.—(a). Connected
with the Fotus. (a). From Abnormal Position.
(i). Face Presentation.
dred cases.
It occurs once in three hun-
Symptoms. You notice the high position of the presenting
part, and make out the forehead, nose, eyes, mouth, etc. Be
careful not to mistake it for breech, and use the greatest gentle-
ness if you suspect a face for fear of injuring the eyes.
Causes. The cause of face presentation is a furtherance of
the slight extension in the early part of labor which is so apt to
produce occipito-posterior, positions.
This extension movement may arise from congenital enlarge-
ment of the thyroid gland which separates the chin from the
chest ; from increased size of the chest, interfering with flexion ;
from stricture of the cervix about the neck of the child, the
uterine walls adding to the circumference of the thorax ; from
mobility of the foetus due to small size or excess of amniotic
fluid ; from oblique position of the child and uterus especially
*n cases of rapid escape of amniotic fluid ; or _ from coiling
cf cord round neck of foetus,
Mechanism. In face presentations the chin cor responds to
the oce
the tw
sible fo
First
Mento-.
of the vy
(1).
the san
The chi
put is p
descent
child’s r
exceptio
the thor
(2). J
inclined
arch, th
sacrum.
(3). J
the shor
stretched
chest, t
brow, ve
(4).
left sho
ond posi
plane, a
according
Second
Here ex
except w
At full
delivery
of the ch
s of
one
the
bd
acted
hun-
ting
Be
ntle- *
ce of
t to
arge-
hn the
kion ;
the
from
hiotic
ially
iling
Re $0
OBSTETRICS. 67
the occiput in vertex presentations, and there are four positions,
the two first being possible, the third and fourth being impos-
sible for d livery to take place.
First. Mento-antertor Position. (Possible). Left and Right-
Mento-Iliac. The movements are s»mewhat varied from those
of the vertex.
(1). Descent and Hxtension, Here extension occurs by
the same rules that produce flexion in vertex presentations.
The chin sinks deeper and deeper in the pelvis, while the occi-
put is pushed backward against the dorsum of the child. The
descent of the head is normally limited by the length of the
child’s neck, as it is only in the case of a very small child, or
exceptionally roomy pelvis, that the head and upper portion of
the thorax can enter the pelvis simultaneously.
(2). Rotation. The chin now impinges on the anterior
inclined plane, rotates forward and engages under the pubic
arch, the vault of the cranium sweeping the hollow of the
sacrum.
(3). Fleaion. The chin now emerges beneath the pubic arch,
the shoulders press upon the base of the skull, the perineum is
stretched by the cranial vault, ths head now flexes upon the
chest, the chin rounds the symphysis while the mouth, nose,
brow, vertex and occiput appear in succession.
(4). Restitution. The shoulders now engage ; in first position
left shoulder impinges on right anterior inclined plane ; in sec-
ond position right shoulder impinges on left anterior inclined
plane, and the chin is thus directed to the left or right thigh
according as it has been first or second position.
Second. Mento-posterior Positions, also called Mento-sacral.
Here extreme extension takes place and delivery is impossible
except with a small foetus, a dead foetus, or a very roomy pelvis.
At full term, with a fully developed foetus and a normal pelvis,
delivery is an impossiility owing.to the simultaneous entrance
of the chest and head. “70 t¢4«*'
68 OBSTETRICS.
Treatment. Be careful not to, rupture the membranes, for the
face is ill adapted to dilate the cervical canal, and rupture of
the membranes in these cases is apt to be followed by complete
escape of the amniotic fluid which would endanger the life of
the child.
Manipulations to push up the face and bring down the occi-
put by pressure of the fingers usually fail. It is better to
restore the normal attitude of the child by flexing the trunk and
leaving the head to resume spontaneously its proper position as
it sinks in the pelvis. It is performed by seizing the shoulder
and breast with the hand through the abdominal walls, then
lifting the chest upward and pressing it backward, at the same
time steadying or raising the breech with the other hand
applied near the fundus, so as to make the long axis of the
child conform to that of the uterus, and finally pressing the
breech directly downwards. As the child is raised the occiput
is allowed to descend and then as the body is bent forward,
flexion of the head is produced by the side walls of the pelvis.
After the membranes are ruptured exercise great care as to
the eyes and admitting air intothe mouth. In mento-posterior
positions the chin may sometimes be brought forwards by one
blade of the forceps acting asa lever.
In these cases, however, if not eariy rectified craniotomy has
usually to be resorted to.
(i). Breech Presentations.
the head of dystocia, not because there is always necessity for
interference, or any danger to the mother, but because there is
danger to the child, and in primipara there is usually
necessity for some intervention on the part of the physician,
utherwise breech presentation might come under the head of
natural labor as some have described it. We may have regular
breech presentations where the legs are bent up in front of the
body, or irregular giving rise to footling and knee presentations.
I have classed these under
The |
is as on
Caus
presence
foetus, |
contract
mature
Diag
high up
and the
Meche
child’s t
ing to th
right an
lst Pe
position
slowly.
Desce
impinges
under th
the sacrv
The de
plane, wl
The he
in the ri
anterior
face swee
of vertex
2nd P¢
lar to firs
to second
3rd Po
position 4
the
a of
lete
. of
ceci-
* to
and
n as
Ider
chen
ame
and
the
the
iput
rar,
lvis.
AS to
prior
one
r has
nder
y for
re is
ally
ian,
hd of
rular
the
ions.
OBSTETRICS. 69
The proportion of breech cases, (excluding premature births),
is as one to sixty.
Causes. The absence of the conditions which determine the
presence of the head, or which interfere with the fixation of the
feetus, such as excess of amniotic fluid, lax uterine walls, and
contractions of the pelvis. They occur very frequently in pre-
mature labors, and when the child is dead.
Diagnosis, The bag of waters is apt to be very large and
high up; the sacrum, coccyx, anus, and tuber ischii are felt ;
and the presence of meconium is positive proof.
Mechanism. The position is defined by the direction of the
child’s back or sacrum, and we have four positions corresp ond-
ing to those of the vertex, viz: Left and right dorso-anterior,
right and left dorso-posterior. ‘
lst Position, Left Dorso-anterior. This corresponds to first.
position of vertex, and is the most common. The cervix dilates
slowly.
Descent and rotation of the hips take place. The left hip
impinges on the right anterior inclined plane and is directed
under the pubic arch, while the right hip sweeps the hollow of
the sacrum.
The /eft shoulder then impinges on the right anterior inclined
plane, while the right shoulder sweeps the hollow of the sacrum.
The head now engages, the long diameter of the head being
in the right oblique diameter, the occiput impinges on left
anterior inclined plane, comes under the pubic arch, while the
face sweeps the hollow of the sacrum precisely as in first position
of vertex.
2nd Position, Right Sacro-anterior. The mechanism is simi-
lav to first position, but reversing the planes, and corresponds
to second position of vertex. ;
3rd Position, Right Sacro-posterior, This corresponds to 3rd
position of vertex, is often converted into 2nd or Ist position
2
Ss
70 OBSTETRICS.
but it may persist and then the chief difficulties are from resist-
ance of coccyx and perineum to flexion, the neck of the child
being thus pushed so far forward that it is difficult for the fore-
head or even for the face to get readily under the pubic arch.
4th Position. Left Sacro-posterior.
MANAGEMENT OF BreEEcH. ‘Try to preserve the membranes
until the os is dilated by avoiding frequent examinations and
cautioning the patient not to strain. After the membranes
are ruptured expulsion of the body should be allowed
to go on slowly, not dragging down a leg as it favors
descent of the cord; the arms are apt to slip up by the side of
the head, and the head is apt to become extended so that the
maximum diameter of the head engages and may become
locked. When the hips are at the vulva be ready to hasten
delivery by telling the mother to strain downward. As the
trunk emerges wrap it in warm flannel and raise it upwards.
When the cord appears draw it down in one of the recesses of
the pelvis and watch its pulsations. With one hand support
the body of the child, with the other, or nurse, sustain a steady
pressure on the fundus outside. The arms may be separately
hooked down.
There are several ways of treating the after-coming head.
1. The Prague Method consists in raising the bédy of
the child towards the abdomen of the mother and by placing
your fingers on the face of the child, or in its mouth, make trac-
tion forwards, This is the usual means resorted to.
2. Martin’s Method consists, besides the above, in making
powerful pressure upon the child’s head externally and above
with the other hand, thus expressing it as it were.
3. Deventer’s Method consists of a reversal of the
Prague method, in that the body of the child is carried far
backwards towards the perineum, with the view of turning the
occiput out from under the pubes, the anterior surface of the
neck resting on the perineum.
4. ]
methoc
(222)
elbow,
The:
import
except
mothe1
treatm
is mucl
Cau
low at
The tei
either |
Diag
and the
abdome
breech
up the
will po
must |}
Agal
back of
or dors
exact }
may br
directio
Posit
sacral o
if the h
and vic
iliac fos
Term
Pyist-
child
fore-
th.
panes
and
ranes
owed
AVOI'S
de of
> the
come
austen
; the
ards.
a3 of
port
eady
ately
ly of
cing
trac-
king
bove
the
far
+ the
the
lod
OBSTETRICS. 71
4. By the Application of Forceps. This is Crede’s.
method and is highly spoken of by some authorities.
(i). Shoulder Presentations, or “cross births,” include
elbow, hand and trunk presentations.
They occur 1; 260 cases. Their management is’ exceedingly
important, for delivery by the natural process is impossible
except under very unusual circumstances, and the safety of
mother and child depend on their early recognition. Their
treatment, easy at first, becomes difficult and dangerous if there .
is much delay.
Causes. Prematurity, hydramnion, obliquity of the uterus,
low attachment of the placenta, and falls duriug pregnancy.
The tendency, however, is for such malpositions to be righted
either before labor sets in, or in its early part. «)¢ . 5 ¢e( gre!
Diagnosis. You will notice at once the high presentation
and the absence of the head. You should then palpate the
abdomen and you will feel the head in one fossa and the
breech in the other. By a digital examination you feel high
up the shoulder, and then the clavicle or axilla. The axilla
will point to the feet and to one side, indicating that the head
must lie in the opposite iliac fossa.
Again, the clavicle indicates the front and the scapula the
back of the child, and so we know whether it is a dorso-anterior
or dorso-posterior position. If you are still not satisfied of the
exact position, and the membranes are already ruptured, you
may bring down the arm, and see which one it is, and in which
direction the palm points.
Positions. Dorso-pubic of right and left shoulder, and dorso-
sacral of right and left shoulder. Thus in dorso-pubic positions ,
if the head lie in the left iliac fossa, the right shoulder presents,
and vice-versa. So in dorso-sacral positions, if head lie in left
iliac fossa, left shoulder presents and vice-versa.
Terminations. There are three possible terminetions which
i a EER DRT TN
SSE TES S/S Tn nS
SIR Aarne Dige onire emp
as ms >
J,
72 OBSTETRICS,
may occur naturally although we can never trust nature to
accomplish them.
1. Spontaneous Rectification. Here the membrane§
are unbroken, and_it takes place by means of the circular fibres
of the uterus; &gsisted by*the patient lying on the opposite side
to which the breech is deflected. The head is made to present.
2. Spontaneous Version. Here the membranes have
been ruptured, one side of the uterus contracts more vigorously
than the other, so that the shoulder is pushed up and the breech
brought down as the presenting part.
3. Spontaneous Evolution. The presenting arm and
shoulder are tightly jammed down and the head is strongly
flexed on the shoulder. As much of the body of the fcetus as
the pelvis will contain becomes engaged, and then rotation
occurs; this brings the body of the child into the antero-
posterior diameter, The shoulder projects under the arch of
the pubis, becomes fixed, and the body of the child becomes
depressed and curved until it is expelled.
Treatment. This consists in turning, or if impacted may
require decapitation, evisceration or embryulcia, for which, see
obstetric operations.
(B). Size and Form. (7). Large Heaps. May give rise to
dystocia and may require forceps, or turning. In these cases
great care should be used in giving ergot.
4
~'\ (i). Derormities. These include hydrocephalus, encephalo-
cele, spina bifida, ascites, and multiple foetuses like the Siamese
cwins.
(y). Number. Muutiete Preenancy. Although the human
female is said to be uniparous, there aré exceptions, and twins
occur ouce in 85 cases, triplets once in 7,000, while quadru-
plets and quintuplets occur still more infrequently.
A co
tion, b
belongi
develop
and mo
by rete
and fru
pregnan!
TWIN
father’s
others ;
It ma
time, w
is prove
develop
sides of ¢
nancy w
A gain
an embr:
When
in its ow
sufficient
ovum wi
own met
are genet
ent circu
Twins
The w
of a singl
usually a
It is al
’ abdomen
distinet f
see
ese
an
ins
ru-
OBSTETRICS. 73
A condition closely connected with this subject is superfota-
tion, by which is meant the fertilization of a second ovum
belonging to another period of ovulation after the first has been
developing for a month or more. Some doubt its possibility
and most of these cases may be explained by a double uterus,
by retention of one twin, by an interval between insemination
and fructification of an ovum, by pre-existing extrauterine
pregnancy and inaccurate information.
Twins. Are often hereditary, and this sometimes runs on the
father’s side ; some races are more apt to have them than
others ; and women married late in life are apt to have twins.
It may occur by two or more ova being fertilized at the same
time, whether they have come from one or different ovaries, as
is proved by the fact of two corpora lutea being found equally
developed ; from the occasional occurrence of pregnancy on both
sides of a double uterus, and from the occurrence of twin preg-
nancy with one foetus in utero and the other extrauterine.
Again, twins may arise from an ovum having a double yolk,
an embryo developing from each.
When twins develop from two ova each foetus is contained
in its own chorion. If the ova are embedded in the decidua at
sufficiently distant points the placente will be separate and each
ovum will have its distinct reflexa. Usually each foetus has its
own membrane and liquor amnii, an although the placentz
are generally united in one mass yet each has its own independ-
ent circulation.
Twins from the same ovum are always of the same sex.
The weight of each child in a case of twins is less than that
of a single delivery, but the conjoined weight is greater. They
usually average five or six pounds each.
It is almost impossible to diagnose twins before birth. The
- abdomen is more distended and broader and you may hear two
distinet foetal heart sounds.
74 ' OBSTETRICS,
Twin labors are usually easy, the first stage is apt to be
tedious from inertia, the second stage is apt to be rapid, and
inertia is apt to occur in the third stage so that post partum
hemorrhage is to be dreaded. The interval ‘between the first
and second child is usually from five to 30 minutes ;- sometimes
both may present heads, but usually one is head and the other
breech. Both placente usually follow the birth of the second
child.
Management. Tie the cord after the birth of the first child
and wait not more than half an hour; if pains do not return,
rupture the membranes, and by external manipulation, the
second child soon follows. The most serious complication is
“locking” i. e., the interference of the second child with the
delivery of the first one. Thus the first child presents a head
but a foot or hand may be found presenting with it. Try aud
determine if it belongs to the first or second child, but in all
cases it should be pushed up as far as possible until the head
has completely engaged in the pelvis.
In all cases of twins there is danger of inertia, and post-
partum hemorrhage is to be anticipated and prevented or
checked.
(6). Connected with the Passages.
(a). PELVIS.
A classification of contrtacted pelvis is difficult ; in the great
proportion of cases, however, the diminution of space is usually
at the brim and it is to these cases that the term “contracted
pelvis” is usually applied, the others being irregular forms.
(t). Con racted Pelvis Proper. 1st. Peivis AQUABILITER
Justo-Minor. This is a symmetrically contracted pelvis charac-
terized by a general diminution of all the diameters, but no devi-
ation, or but little, from their relative proportion in the normal
pelvis. [tis simply below the standard size, and is due to a
premature arrest in the development of the bones so that the
pelvis retains its infantile type. |
2nd.
shorte:
itic or
burder
to oste
a shall:
of the
mainly
presses
the san
of the °
the sac
superio
3rd.
combin
the tra
rachitic
(22).
PELVISs.
synchor
sacrum
side.
outside
2nd.
ture or
ral dire
which is
tory bei
is rende
and the
3rd.
eral cur
arch, pr’
> be
and
tum
first
mes
ther
ond
shild
urn,
_ the
yn is
1 the
head
aud
n all
head
post-
d or
OBSTETRICS, 75
2nd. Tue Fratrenep Petvis. Herethe conjugate diameter is
shortened but the transverse remains normal. It may be rach-
itic or non-rachitic, and is often due to lifting or carrying heavy
burdens before the age of puberty, to arrest of development, or
to osteomalacia, The result of these conditions is to produce
a shallow pelvis with a contraction at the brim and a widening
of the outlet. This deformity, when resulting from rickets, is
mainly due to the weight of the super-imposed body, which
presses the promontory forwards toward the median line, At
the same time the sacrum is rendered more horizontal, the bodies
of the vertebree sink between the ale so that the concavity of
the sacrum from side to side is effaced, und the posterior
superior spinous processes are approximated.
3rd. FLATTENED GENERALLY ContR\CTED Petvis. Thisis a
combination of the other two varieties and there is narrowing in
the transverse as well as the conjugate diameter. It may be
rachitic or non-rachitic.
(ix). Irregular contracted Pelvis, st. THE N®GELE OBLIQUE
Petvis. This consists in complete anchylosis of one sacrc-iliac
synchondrosis, in destruction or defective development of the
sacrum on that side, and displacement towards the anchylosed
side. The cavity is obliquely ovate. You notice an inequality
outside and the patient limps.
2nd. Tue Kypnoric Petvis. Is due to posterior spinal curva-
ture or caries of the vertebree, and as a result of this an unnatu-
ral direction is given to the weight of the superimposed trunk,
which is communicated to the base of the sacrum, the promon-
tory being thus thrust upwards and backwards, the symphysis
is rendered prominent, the transverse diameters are diminished,
and the conjugate increased.
3rd, Tue Scouio-Racuitic. This accompanies scoliosis or lat-
eral curvature of the spine. There is expansion of the pubic
arch, prominence and lowering of the promontory, widening and
tre gs
z 8 OO
& - = = ~
e’4
PG’ Ss GN Ae
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76 OBSTETRICS.
elongation of the sacrum and irregular kidney-shaped pelvic
inlet, the pelvis being laterally tilted and asymmetrical.
DIAGNosIs OF ConTRACTED PeLvis. On enquiring into the his-
tory vou usually find a previous occurrence of rickets indicated
by late dentition, square head, pigeon breast, attacks of indiges-
tion and profuse perspiration, tumefied abdomen, small stature,
spinal curvature, enlarged joints, and bow-legs. Then an
‘enquiry into the }revious labors, if there have been such, will
throw light on the case.
MEASUREMENT.
1. Internal Pelvimetry. The patient is placed upon
the back and the diameter which is now of importance is
the diagonal conjugate or sacro-subpubic, and is the distance
from the promontory of the sacrum to the lower border of
the symphysis pubis. It may be measured by the pelvi-
meter, but the fingers are best. While the point of the
finger touches the promontory ot the sacrum, mark off on the
back of hand the under border of symphysis and deduct half an
inch, this will give the conjugate diameter,
2. External Pelvimetry. Measure with a pair of cal-
lipers from the upper edge of the pubic symphysis to the depres-
sion just below the spinous process of the last lumber vertebra.
This is normally 7? inches and “educting 34 inches for the thick-
ness of bone and soft parts, you have 4} inches as the conjugate
diameter. Then the distance between the two anterior superior
spinous processes should be normally 94 inches, and between the
two most projecting points laterally on the crests of the ilia
should normally measure 103 inches.
I append the c rresponding normal diameters and dimens-
ions, as given by Carl Braun and Schroeder :
Distance between anterior superior spinous Inches.
DODO iis i+ ed bus bine weenie ace brane 26 cm. or 10,2
Distance between iliac crests............ 29 cm. “ 11.4
retrove
ceratior
in norn
pendulc
2. I
high, a
pains a
tion is”
ism in -
compre
shape o
quity, |
from ev
Trea
tion of
abdomi:
operatic
befor
enquire
does th
labor ;
through
living,
ic
OBSTETRICS. rhe 4
External conjugate diameter (Baudelocque) 20} cm. or 7.9
Distance from sacro-coccy geal joint to sub-
public joint (A. G. E. Breisky)...... 12.30m. “ 4.8
Distance between great trochanters...... 313 om. “ 12.3
Pelvic circumference (Kiwisch)........ 90 em. “ 35.4
Diagonal conjugate diameter............ 13 cm. “ 5,1
True conjugate diameter................ Ll cm. “ 4.3
INFLUENCE DURING PREGNANCY AND LABOR.
1. During Pregnancy. In the early months it favors
retroversion and this gradually merges into flexion and incar-
ceration. In the later months the uterus is elevated more than
in normal cases and is more movable, and the abdomen is more
pendulous.
2. During Labor. The presenting part is always very
high, and faulty presentations are more apt to occur. The
pains are apt to be strong and hence if the mechanical obstruc-
tion is not removed the uterus is apt to rupture. The mechan-
ism in these cases will depend on the size, form, position, and
compressibility of the foetal head, as well as on the size and
shape of the pelvic space. There is usually more lateral obli-
quity, because the contracted pelvis prevents both parietal bones
from entering at once.
Treatment. Our resources in contracted pelvis are the induc-
tion of premature labor, forceps, version, craniotomy, and
abdominal section, for an account of which, see obstetric
operations.
before deciding the appropriate method it is important to
enquire if pregnancy has advanced to the full term ; if not,
does the case call for the induction of abortion or premature
labor ; if the term has been reached, is it possible to deliver
through the natural passage ; if the child is alive or dead; if
living, do the interests of the mother require the sacrifice of
78 OBSTETRICS.
the child’s life ; and lastly, if the conditions are such as to ren-
der it impossible for a living child to be born, what method
would be best for the interests of both mother and child ?
To answer these questions it will assist if we divide contrac-
ted pelvis into four degrees :—
First Degree. Where the conjvzate diameter is between 4
and 34 inches, the forceps are indicated.
It is assumed that the child may be born alive by the spon-
taneous efforts of the mother, but it seems to be forgotten that
a Jarge proportion of children will perish and the mothers
suffer greatly, and their tissues be lacerated, unless assisted.
The dangers to the child result from pressure obstructing the
circulation, and the dangers to the :1nother from long continued
pressure on the soft parts, causing inflammation and subsequent
sloughing of the bladder, vagina or urethra. These results
have been attributed to the forceps but are really due to neglect
of their timely use.
Second Degree. Where the conjugate diameter is between
34 and 23 inches, version is indicated.
Here labor unassisted is hopeless for both mother and child.
By turning you bring the narrow part of the head (the bi-tem-
poral diameter, 34 inches) to engage first in the narrowed con-
jugate, which the wider dome of the head could not do, and
then after turning, manual abdominal pressure may be applied
to the head and traction on the body from below.
If the child is dead it is always preferable in such a case to
perforate and deliver.
Third Degree. Where the conjugate diameter is from 23 to
1? inches, here craniotomy is indicated, or if the child be alive
and not injured by delay or futile attempts to deliver in other
ways, and provided the general condition of the mother, her
hygienic surroundings and capacity to secure skilled attendants
be such
section,
vided al
Fourt
1? inche
and dan;
To rec
When
brit
Bet
(2). O
being m
ontory c
is notice
hard to.
Treats
with the
or apply
Later:
on the 0;
(i). I
delay in
of the lic
and emo
edges of
It ofte
and who
OBSTETRICS. 79
be such as to give substantial hope of her surviving abdominal
section, this operation would be justifiable and preferable, p o-
vided also that she and her relatives consent.
Fourth Degree. When the conjugate diameter is less than
1? inches, abdominal section is, beyond all question, less difficult
and dangerous than craniotomy.
To recapitulate :—
When conjugate diameter of
brim measures .
The proper mode of
delivery is by :
Between 4 and 34 inches............... Forceps.
Ms Shand 2 “ 1. .......00.. Version.
sh 2$and1¢ « . Craniotomy,
or if child alive, by Abdominal Aboticn.
Below 1? inches. . . Abdominal
Section and not C1 ening
(8). OS UTERI.
(z). OBLiquity. This may be lateral or anterior, the latter
being more common ; the head is thrown toward the prom-
ontory of the sacrum, and labor is thus impeded. The uterus
is noticed to be thrown forward, the belly pendulous, and it is
hard to find the os as it is so far back.
Treatment. Rupture the membranes, draw forward’ the os
with the finger, and press on the abdomen with the other hand
or apply a binder.
Lateral obliquity is often relieved by making the patient lie
on the opposite side.
(i), Rigipity. This is one of the most common causes of
delay in the first stage, and is often caused by premature escape
of the liquor amnii. It is very often found in those of a nervous
and emotional temperament, the pains becoming cramp-like, the
edges of the os being thinly stretched over the head.
It often occurs in girls who have been brought up in luxury,
and who bave had little physical exercise, the exciting causes
a ae
et
it
(
,
80 OBSTETRICS.
being powerful impressions on the mind, over-stimulating food
or drinks, or too frequent examinations on the part of the
physician. 7/?*&+-e agin
Treatment. If the membranes are intact, waiting and patience
often succeed, but if the membranes are ruptured you may
need to assist, for itis often in these cases that laceration of the
cervix orcurs. Use first the hot vaginal douche, and if this is
not sufficient give chloral hydrate in gr. XVdoses every half
hour for three doses. It often acts well and does not interfere
with the strength of the pains. In some cases, where due to
severe continuous pains, chloroform is often more useful.
(iat). INpuRATION. This may be due to cicatricial hardening
from former lacerations ; to hypertrophy of the cervix from dis-
ease antecedent to pregnancy, or to aglutination and closure of
the os.
Treatment. Try the same means as in rigidity, and if these
fail, it may be necessary to make three or ‘our notches round
the margin of the os with a blunt-pointed bistoury. Should
these fail, especially in cancerous disease, craniotomy or
Ceesarean section may be necessary.
(y). VAGINA.
(2). Arresia, This may be congenital or it may be acquired
from lacerations, diphtheria, variola, enteric fever, cholera or
syphilis. Persistent nymen comes under this head.
Treatment. The same as that of rigidity or induration of
the os.
(iz). Tumors. These include cedema of the labia, sanguineous
effusions, displacements of the bladder, scybala in the rectum,
calculi in the bladder, encysted tumors of the vulva, fibroids,
steatoma, polypi, scirrhus and ovarian tumors.
Treatment, This depends on their character and mobility. If
they do not interfere with labor let them alone, if they obstruct
they
by itse
(C).
(7).
consids
tensior
T rec
water |
(27).
premat
(6).
and git
and rec
Cy).
child if
separat
(i),
After
where t
hastene
(v2).
endange
child wl
Cause
insertio
lapse of
above al
Progr
more se
occurs a
Treat
maintain
,
DUS
OBSTETRICS. 81
they may need removal, but every case will have to be judged
by itself.
(c). CONNECTED WITH THE SEcuNDINES. (a). Liquor AMNII.
(i). ABuNDANT. This is hydramnion. which has already been
considered. It impedes labor in the first stage and by over-dis-
tension paralyzes the uterus.
Treatment. Puncture the membranes high up and allow the
water to escape slowly if possible. .
(aw). Dericient. This may delay labor for the same reason as
premature rupture of the membranes.
(8). THe Mempranes. Thin membranes rupture prematurely
and give rise to “ dry births,”
and require to be punctured.
or if tough they may cause delay
(y). THe Corp. (2). SHort. Gives rise to danger to the
child if it tears and bleeds, or to the mother from premature
separation of the placenta and hemorrhage.
(%), Enranetup. It is often twisted round the child’s neck.
After the head is born it may be slipped over its head, and
where this cannot be done it may be tied and cut, and delivery
hastened
(iii). PRESENTING. ‘“‘ Prolapse of the funis,” although uct
endangering the mother, is serious as regards the life of the
child which is very apt to be sacrificed.
Causes. Unusual length of the cord, deep placental site,
insertio velamentosa, 1 -ulder ana breech presentations, pro-
lapse of the extremities, hydramnion, multiple pregnancies, and
_ above all contracted pelvis. —
Prognosis. More than one-half of the children die. It is
more serious when it complicates head presentations. It
occurs as 1; 300 cases.
Treatment. Ifthe membranes are not ruptured try and
maintain them so, for the expectant plan is best until dilatation
" :
ROT SORE SLT EERE ELTON Oa ee a
- ———-
x " rE penenon ~ —
a a Re EIS
Ed
Pa. f ‘
82 OBSTETRICS.
is complete. After rupture of the membranes, if the presen-
tation is still high, the cord should be replaced and held up
until the child has engaged.
_/ This is best done by placing the patient in the genu-pectoral
position ; introduce the hand and place the cord beyond the
greatest circumference of the head, and if possible, to the back of
the child’s neck; sustain the uterus externally by the other hand,
and cease during the pains. If this is successful place the patient
in the latero-prone position with the hips elevated by a pillow.
If this should fail, put a piece of tape through the eye of a flex-
ible catheter, and catching a loop of the cord with this push it
into the uterus and leave the catheter there until the head
engages so as to prevent prolapse again. If these means fail,
especially in face presentations, version may be resorted to.
(5). Puacenta. (2). ADHESION. lst. SimpLeE RETENTION,
May be caused by spasm of the os; from maluse of ergot ;
large size of placenta ; or from dragging on cord so as to pull
placenta against the pubic arch, or invert it so that it is like
dragging on an umbrella; this has been sty'ed “ student’s
placenta.” @%er 4% Ue. btn.
Treatment. There is always danger of hemorrhage while the
placenta remains in the uterus, so if Crede’s method of removal,
together with gentle traction, are not sufficent, introduce the
hand, dilate the os, and remove the placenta.
2nd. Hour-eiass Contraction. Here portions of the uterus
contract feebly, while the circular fibres are thrown into spasm
and retain the placenta in the fundus. It may be caused by
the maluse of ergot, or by premature dragging on the cord.
Treatment. Place the patient on her back, your left hand on
the abdomen to steady the uterus, and with the right hand fol-
low up the cord, gradually dilate the constricted part with two
fingers, and seizing the placenta remove it.
3rd. Morsip ADHESION. May be uterine or placental. The
nlace!
careot
the pl
it. T
uterus
and w
have {
no spe
Tre
placen
the pl.
moven
the pl:
Exe
for he
care sh
the ut«
employ
(22).
the ute
segmen
leaves 1
pours u
vention
natural
hemorr!
ment of
on the
hemorrl
Band
different
stretchii
cervix.
OBSTETRICS. 83
nlacenta may be thickened, indurated, or have undergone cal-
careous degeneratio . There may have been inflammation, and
the placenta may be adherent in whole or in part as a result of
it. Though it is rare it may be presumed to exist when the
uterus is large, firmly contracted, the os sufficiently opened,
and where suitable traction on the cord and external pressure
have failed to remove it, and on digital examination you find
no spasmodic stricture of the os or uterus.
Treatment. If the means for removing a simply retained
placenta are not sufficient, insert your fingers carefully between
the placenta and the uterine surface, and by slow and cautious
movements of the fingers the adhesions ure bruken down and
the placenta freed.
Exert no force and be careful not to injure the uterine tissue
for hemorrhage, rupture, or inflammation may follow. Great
care should be taken after these cases to use disinfectants, and
the uterine douche with bichloride (1-5,000).should always be
employed.
(iz). Pravia. Is where the placenta occupies that portion of
the uterus subject to dilatation i. e., the internal os and lower
segment of the uterus. The stretching of the lower segment
leaves the mouths of the sinuses gaping, from which the blood
pours until the stream is arrested either by art or by the super-
vention of syncope. As the hemorrhage in such cases is the
natural sequence of cervical dilatation, it is called “ unavoidable
hemorrhage ” in contradistinction to hemorrhage from detach-
ment of the placenta when situated normally at the fundus or
on the side walls of the uterus, which is known as “ accidental
hemorrhage.”
Bandl has shown that during labor the uterine body becomes
differentiated into a retracting and ever thickening fundus, a
stretching and ever-thinning “lower uterine segment,” and the
cervix. It is not yet finally settled what is cervix and what is
3
—
Sapper
ee ee ee ray * a " “ = pe
SAI AB RR RI CCT HER RI SEN NTL TAILS TERI RS MP . —
84 OBSTETRICS.
‘lower uterine segment.” After labor the lower uterine seg-
ment and cervix can be felt at the lower part of the hard
retracted uterus, hanging loosely like a flabby hose.
Placenta previa may be central or marginal, called also
partial.
It occurs as 1: 1,000 cases.
Causes. It occurs more frequently in multipara than in
primipara in the proportion of 6 to 1; more frequent in those
who have had children rapidly, and in pregnancies shortly fol-
lowing abortions. All these conditions favor relaxation of the
uterine walls, dilatation of the uterine cavity, subinvolution of
the uterus, and defective development of the decidua,
Symptoms. Sudden hemorrhage occurring during the last
few weeks of pregnancy without any apparent cause, without
warning or pain, often while urinating or asleep. The first out:
pouring may lead to intense anemia, and if shortly repeated
may cause death. It usually ceases when separation of the
cotyledons is completed, and after rupture of the membranes,
for then pressure of the presenting part bears upon the bleeding
The hemorrhage is usually arrested during the height
surface.
of the pains. :
Diagnosis. Itis not usually detected until the first hemor-
rhage occurs. :
A sudden hemorrhage occurring during the last few weeks
of pregnancy, without warning, cause, or pain, should always
be regarded as suspicious of placenta previa. On making a
digital examination the os ‘is felt to be soft and boggy, balotte-
ment is obscure, the cervix is long, wide, soft, and you can often
feel vessels pulsating in it, and you can usually feel the rough,
spongy, granular texture of the placenta within the os.
Prognosis. Js unfavorable if left to nature or if not promptly
assisted. No complication in midwifery is more apt to produce
sudden and alarming effects, and none requires more prompt
and |
to th
case |
from
Tr.
the w
exists
of suc
and h
quent
ting, |
promy
doing
chance
We
gress t
This is
it is n
has be
placent
Simpsc
placent
placent
not, ho
accordi
If th
septic p
the co1
escapin,
the tan
g-
rd
sO
OBSTETRICS. 85
and scientific treatment. There are few cases more appalling
to the young practitioner, and the successful management of a
case of this kind at once distinguishes the educated accoucheur
from the ignorant midwife.
Treatment. Always remember that there is no safety fi
the mother as long as pregnancy continues if a placenta previ:
exists. When, theref re, you have been summoned to a case
of sudden hemorrhage during the latter months of pregnancy
and have diagnosed placenta previa, delay is dangerous. Fre-
quent recurrence of such hemorrhage may be seriously exhaus-
ting, or one repetition may be fatal, and if we have not acted
promptly, perhaps all we shall then have the opportunity of
doing will be to regret that we did not act when we had the
chance.
We must remember that a certain number of these cases pro-
gress to a favorable termination and require no interference.
This is more apt to occur in placenta previa marginalis, although
it is not unknown in placenta previa centralis, where the child
has been known to he born by strong contractions pushing the
placenta out like a cap upon its head. It was on this fact that
Simpson’s treatment, consisting in the previous removal of the
placenta with the. hand, and Barnes’ method of detaching the
placenta from the lower uterine segment, depend. We must
not, however, leave it to nature, but each case must be treated
according to its condition.
If the os is not dilated you must plug, using of course anti-
septic precautions. The tampon strengthens the pains and by
the compression it exerts, causes coagulation of the blood
escaping from the uterine vessels. Having once introduced
the tampon you should never leave the patient until labor is
ended.
After at most fowr hours, the plug should be removed and
the cervix examined. If the attachment of the placenta has
i
H
86 OBSTETRICS,
only been slight to the lower zone, hemorrhage may now cease,
the presenting part preventing any more, and the case may be
allowed to proceed, or you may hasten delivery by ergot or
forceps.
Barnes recommends separating at once that portion of the
placenta Which is attached above the inner orifice of the cervix.
By so doing he says “ we remove an obstacle to dilatation of
the cervix, for the adherent placenta acts as an impediment.”
‘Pass one or two fingers as far as they will go through the os
uteri, the hand being passed into the vagina if necessary ; feel-
ing the placenta, insinuate the finger between it and the uterine
wall, sweep the finger around in a circle so as to separate the
placenta as far as the finger can reach. Commonly some
amount of retraction of the cervix takes place and the hemor-
rhage ceases.” :
Should these means not succeed you can rupture the mem-
branes, give ergot and hasten the engagement of the foetus and
its delivery. Should hemorrhage still persist, turn by Braxton
Hicks’ method, bring down one leg and let the case go on natu-
rally, as it is quite unnecessary to extract. In placenta
previa centralis the hand should be passed through the least
attached portion and the child turned, a leg brought down, ard
then lett to nature.
In all these cases the most careful antiseptic precautions
should be employed after delivery, as sepsis is apt to occur from
the low placental site bringiny it nearer to the outer world, and
nearer the accoucheur’s fingers, owing to laceration, and perhaps
to imperfect retraction of the lower uterine segment.
3. Complications of Labor. (a). Hemorrwace.
(a). ACCIDENTAL HEMORRHAGE.
This is hemorrhage occurring during pregnancy or labor owing
to partial separation of the placenta when normally attached. : It
is rare in primipara, and usually occurs in debilitated multipara.
Ca
ing,
uteru:
allow:
uterus
Sy
depen
If t
may |
lapse,
Die
of pre
on dig
Occ
uterus
the lic
is rece
escape
Pro
but th
guarde
Tre
fectly
If it
not stc
deliver
(See
Thi
may fo
a few n
unders
et US
OBSTETRICS. 87
Causes. Slipping, straining, lifting heavy weights, stretch-
ing, blows, congestion of the « terine vessels, causing the
uterus to contract, and the partia. separation of the placenta,
allowing the blood to escape between the membranes and the
uterus,
Symptoms. More or less bleeding, which is often profuse,
depending on the exciting cause.
If the blood collects between the placenta and membranes it
may be “concealed” or “occult” and is recognised by col-
lapse, pain and distension of the uterus.
Diagnosis. Hemorrhage occurring during the latter months
of pregnancy, the bleeding being increased during the pains, and
on digital examination an absence of placenta previa.
Occult hemorrhage is to be distinguished from rupture of the
uterus. In the latter, labor has been going on for some time,
the liquor amnii has escaped, the severe labor pains cease, there
is recession of the presenting part, severe pain in abdomen, and
escape of foetus into the abdominal cavity.
Prognosis. The death rate of the mcther is about 15 p.c.,
but that of the child is very high, so you should always give a
guarded opinion as to the child.
Treatment. If very slight keep the patient in bed and per-
fectly quiet, giving refrigerent drinks.
If it still continues rupture the membranes, and if this does
not stop it, use tampon or Barnes’ dilators to dilate the os, and
deliver by forceps or version, using ergot to hasten the labor.
(8) UNAVOIDABLE HEMORRHAGE.
(See Placenta preevia).
(y). POST PARTUM HEMORRHAGE.
This is by no means an uncommon complication of labor, and
may follow the simplest and easiest labors bringing the patient in
a few moments to the brink of the grave, hence the importance of
understanding its cause, mode of prevention and treatment.
mae nen ne A Rasta ith en sini eps opnomeneern
« — a: ree < " .
eugene
a
jane
BREA
ean, ey iar
4
A i
88 OBSTETRICS,
Symptoms. The bleeding may vccur after the birth of the
child and before expulsion of placenta, but is usually applied
to hemorrhage occurring after the completion of the third
stage.
It may commence gradually or it may be sudden, and in
severe cases so abundant as to deluge the clothes, bedding and
even the floor. The hand on the abdomen misses the hard con-
tracted uterus and instead it is felt large and soft and flabby.
The pulse is rapidly affected becoming thready or impercept-
ible. There is intense weakness or faintness, yawning, restless-
ness, gasping, she cries out for air, skin cold and covered with
perspiration, loss of vision, ringing in ears, twitching, con-
vulsions and finally death.
Such is the course of a fatal case, but recovery often takes
place when the patient is at a very low ebb.
There is probably no complication of labor in which the life
of your patient so much depends upon your presence of mind,
skill and resources ; by your assistance she will generally sur-
vive, without it she will usually perish. You must therefore
be prepared to act instantly, and decisively.
Causes. The cause is inertia or atony of the uterus which
may result from exhausting labor, rapid evacuation of the uterus,
excessive distension, nervous depression, severe general sia aa
retained placenta, sudden rising up, etc.
Treatment. As the causes arise from disturbances of the
mechanism by which hemorrhage is normally prevented, the
treatment consists in following nature’s method, viz., securing
firm contraction and retraction of the uterus.
Retraction is an important factor in the arrest of post partum
hemorrhage, and by it is meant that reduction of the size of the
uterus and thickening of its walls which is not followed by relax-
ation and expansion. Hence the blood is squeezed out of the
uterir
portio
Pre
orrhay
measu
quick]
use of
uterus
ineum
soon a
pressu
Ker
firmly
Sho
remov
micall
an equ
fingers
then ¢
ure fre
Shot
hot wa
failing,
Sho
hypode
Last
injectio
are dat
The.
auto-trs
fusion
of a sa
dr. 4,
OBSTETRICS. 89
|
the uterine sinuses and the vessels more thoroughly closed in pro-
ied portion to the thorough retraction of the uterus. |
ird Prophylaxis, .If there has been a history of previous hem- i
orrhage, she should be treated by tonics and general hygienic 1"
in measures during pregnancy. Then be careful not to deliver too i |
und quickly, avoid all unnecessary traction on the cord, avoid the ; |
on- use of chloroform, and try to secure regular contraction of the a
; uterus, giving a dose of ergot as the head comes upon the per- i li
spt. ineum. Be im no haste to deliver the body of the child. As 4 |
het soon as it is born keep your hand on ,the fundus, making firm
ith pressure on it or gentle friction.
son- Remove the placenta by expression and then hold tie uterus
firmly for half an hour or even longer if necessary.
kes Should hemorrhage occur in spite of these precautions,
remove pillows from under the patient’s head, inject hypoder-
life mically 2 gr. of ergotine, or $ dr. fluid ext. of ergot, diluted with
an equal quantity of water, into the gluteal region. Introduce
ie fingers or hand into vagina or uterus and remove clots, and
ee then press fingers firmly against cervix making counter-pres- :
ure from the outside. ;
Should this fail place a bed-pan under the patient and inject 1
hich hot water into the uterus at a temperature of 112° F. This ;
vive, failing, inject in,same way a tumbler full of brandy or whisky.
i Should} the patient be very faint, inject brandy or ether
hypodermically, |
the Lastly ice has been employed, and Barnes recommends the 1
the injection of perchloride of iron, and Trask uses iodine, but they L f
ms are dangerous remedies. 1 :
The anemia resulting from loss of blood may be treated by i :
um auto-transfusion, i. e., by bandaging the limbs, by the trans- |
the fusion of blood by Aveling’s apparatus or by the tra. sfusion if
Hax- of a saline solution, (common salt dr, i, bicarbonate of soda | '
the dr, 4, warm water, | pint at temp. 100° F).
90 OBSTETRICS.
SECONDARY UTERINE Hemorruace. May appear several
hours, or days, or even a week or two after labor, and usually
results from the retention of portions of placenta, or clots, or
from partial relaxation or want of tone of the uterus, or to
congestion of the uterus from some mental shock, or deficient or
absent lactation.
Treatment. Remove clots or portions of placenta, if retained,
and give ergot to cause the uterine tissue to condense.
(6). HCLAMPSIA OR PUERPERAL CONVULSIONS.
Few of the complications of labor are more terrible or fatal.
It is peculiar to the puerperal state, occurring only during
pregnancy, labor, or after delivery; it resembles epilepsy, and is
not to be confounded with hysteria or apoplexy. It occurs once
in 500 labors.
Symptoms. The premonitory symptoms are headache, vertigo,
* loss of memory, flashes of light. before the eyes, contracted pupil,
ambliopia, ringing in the ears, nausea, vomiting, dyspnea
cedema of the face and extremities, and finally the, presence of
albumen and tube casts in the urine. 4 + datins
Then the convulsions are ushered in, often suddenly, by
twitching of the face muscles, rolling up of eyes, closed jaws, and
insensibility, the pulse intermitting, and respiration being sus-
pended. This lasts from one to five minutes and then the
lividity of the face diminishes, the skin becomes warmer, the
pulse fuller and consciousness partially returns.
In from a few minutes to an hour the fit recurs, and so on,
the intervals diminishing and the fits lasting longer, and the
unconsciousness becoming more marked. 7
Prognosis. The mortality is about 25 per cent.
In favorable cases, after expulsion of the uterine contents, the
attacks cease or diminish in frequency, and the coma disappears,.
ending in natural sleep. On awaking the patient complains of
heatac
either |
occur ¢
deeper
kidney
childre
danger
hemorr
Path
found i
pregna
headacl
the pre
a tende
for duri
salts are
of fibrin
In 18
seizures
associate
stantly
resem bl.
convulsi
“ occurs
and it be
and com.
ureemic -
tion it a
This vy
peral ec
synonym
Seyfer
1. Tha
OBSTETRICS. 9]
heatache and impaired memory, and has no recollection of
either the fits or the lucid intervals. The earlier the convulsions
occur during labor the longer or more difficult the delivery, the
deeper the coma; and the greater the insufficiency of the
kidneys the worse the prognosis. Usually one half of the
children are stillborn. Even after consciousness returns the
danger is still not ended. There is a tendency to post partum
hemorrhage, inflammation, hemiplegia, mania, and epilepsy.
Pathology and Causation. The predisposing causes are
found in the increased excitability of the nervous system in the
pregnant woman so that she is more liable to spasms, cramps,
headache, neuralgia and all nervous affections. In this respect
the pregnant woman resembles the young child. Then there is
a tendency to plethora and a hydremic condition of the blood,
for during pregnancy the red blood discs, the albumen, iron and
salts are diminished, while the white blood discs, the elements
of fibrin and the water of the blood are increased.
In 1842 Lever noticed the coincidence between the convulsive
seizures and renal insufficiency, which may or may not be
associated with albumenuria, though the two go pretty con-
stantly together. In 1851 Frericks pointed out the close
resemblance between puerperal convulsions and the uremic
convulsions of Bright’s disease. ‘‘True eclampsia,” he says,
“occurs only in pregnant women suffering with Bright’s disease,
and it bears to the latter the same causal relation as convulsions
and coma in Bright’s disease in general ; it is the result of the
uremic intoxication with which also in its mode of manifesta-
tion it agrees.”
This view was strenthened by Braun, in 1857, so that puer-
peral convulsions and uremia came to be regarded as
synonymous, ,
Seyfert thus states the objections to this theory :—
1. That convulsions may occur without albumenuria,
ores a SP NT
. a
eee
92 OBSTETRICS.
2. That the albumenuria is in many cases the effect and not
the cause.
3. That in many fatal cases the kidney lesions were absent
or wholly insignificant,
4. That convulsions are rare in chronic Bright’s disease
which had existed prior to pregnancy.
5. That in true uremia, such as is necessarily produced by
the suppression of urine, as, in uterine cancer, where the ureters
are invaded, convulsions no not occur.
Although these propositions are perfectly correct, in drawing
conclusions from them unnecessary stress is laid upon the
presence or absence of albumen in the urine. It is the renal
insufficiency and not albumenuria which causes uremia and
the convulsions.
What then is the exciting cause, for convulsions do not occur
in every case of Bright’s disease, nor even in every case of
renal insufficiency. Frericks thought he had found it in sup-
posing a ferment which converted the urea into ammonia
carbonate.
A more scientific explanation, and the one now generally
received, is the Traube-Rosenstein theory which maintains that
“eclampsia takes place when, in persons rendered hydremic
by the loss of albumen, the aortic pressure was suddenly
increased (as it is by the pains), the increased pressure giving
rise successively to cedema of the brain, then to secondary com-
pression of the vessels, and finally to acute anemia.” An
anemic condition of tne hemispheres gives rise to coma, while
if extended to the motor centres, it causes convulsions.
Treatment. Prophylaxis. C&dema of the face and legs
should lead you to at once examiae the urine, and finding aibu-
men, put the patient on milk diet, avoiding meat and
albuminous food. Saline cathartics, tonics containing iron, use
of mins
fail in
steadil:
Whe
and flu
section
dermicé
object i
deliver:
digital
and ap
bromid
and ren
In a
loss of
of the
ing. |
more se
In thes
nerve ¢
diminis!
gradual.
trunks f
the fort
form ew
in some
~ or heart
Wher
vapid, it
toms, a
Treat
or a hyp
not
ent
2aSe
OBSTETRICS, 93
of mineral waters, and the Turkish bath. Should all efforts
fail in removing the cedema and albumenuria, and should these
steadily increase, you should resort to premature labor.
When the convulsions have set in, use chloroform inhalations
and fluid extract veratrum viride, gtta. 4 every 2 hours. Vene-
section is useful in well selected cases, or you may inject hypo-
dermically morphia, gr. }, or pilocarpine gr. 4. Then the great
object is to evacuate the contents of the uterus by hastening
delivery. If the os is not dilated use hot water injections and
digital manipulation or Barnes’ dilators, rupture memoranes
and apply forceps or turn. Afterwards rectal injections of
bromide and chloral, and means to restore the renal insufficiency
and remove the cedema and albumenuria.
(c)) SYNCOPE.
In a large majority of cases this is merely a symptom of
loss of blood, or exhaustion, or of nervous origin, and one
of the phases of hysteria, in which case it is not alarm-
ing. It occasionaily happens, however, that syncope is far
more serious, and is occasionally followed by collapse and death.
In these cases it is cause by the recession of blood from the
nerve centres when the intra-abdominal pressure is suddenly
diminished by the rapid emptying of the uterus. The arteries,
gradually in such cases, become empty, while the large venous
trunks fill with blood, and the sluggish current predisposes to
the formation of thrombi, which are prone to disintegrate and
form emboli, which get into the circulation and become arrested
in some venous plexus or obstruct the circulation in the brain
or heart.
Whenever the pulse, after delivery, continues feeble, and
vapid, it should be, even in the absence of other grave symp-
toms, a subject of profound alarm.
Treatment. Lower the head, give stimulants by the mouth
or a hypodermic of brandy or ether. at tine? ahi“ ad de
SEL AE IEF IONS EO LEY
94 OBSTETRICS.
Much can be done in the way of prevention, as by avoi‘ling
the occurrence of post-partum hemorrhage, not allowing the
labor to be too long continued, preventing the patient from
suddenly rising in bed, and applying compression tv the abdo-
men, by the hand and binder.
(d)) INVERSION OF THE UTERUS.
By the condition of acute inversion of the uterus, is
meant the depression of the fundus into the cavity of the
uterus, which may continue to increase until not only the
fundus but the whole body and cervix have passed through the
os uteri, the organ being literally turned inside out.
It is rare, occurring only once in }40,000 cases.
Causes. Predisposing. Inertia is the almost exclusive
cause,
The exciting causes are traction on cord, especially when pla-
centa is adherent; artificial attempts at extracting placenta,
especially when accompanied by bearing down efforts on the
part of the woman ; and lastly a short or entangled cord may
produce it by dragging upon the placental attachment during
the birth of the child.
Symptoms. These depend on whether it is partial or com-
plete, but usually there is great distress and severe pain, great
depression and often collapse, indicated by fainting, small pulse,
cold clammy skin, and she may die from shock.
On placing the hand upon the abdomen a cup shaped depres-
sion of the fundus is felt, and in the vagina the uterus can be
felt more or less inverted. The patient has a feeling of pressure
and bearing down, and usually there is more or less hemorrhage.
If the inversion is slight, spontaneous restoration
The more complete the inversion the more danger,
Prognosis.
may occur.
and the patient often dies from shock or hemorrhage.
Trea
and ski
and ho
introve
with t'
bougie.
to give
This
eXcessi\
Tt oc
Cause
of the w
deformi
passage
tissue.
The e
external
turning.
The x
hence, if
or ruptu
there n.:
Loot
the cervi
cervix, 0.
abdomin,
fibro-mu:
Sympt
when the
plains of
abdomen
OBSTETRICS. 95
Treatment. Everything depends upon promptness, decision
and skill. If only slight, insert the finger, or a conical bougie
and hold it in position until the uterus contracts. If it is
introverted do not remove the placenta, but seize the tumor
with the hand or push up the fundus with the fingers or
bougie. You may require to use chloroform, and afterwards
to give opium.
(). RUPTURE OF THE UTERUS.
This terrible and often fatal accident of labor is the result of
excessive muscular contractions of the uterus.
It occurs once in 1,500 cases.
Causes. The predisposing causes are preternatural thinness
of the walls of the uterus, hydramnion, shoulder presentations,
deformities of the pelvis, or anything. which obstructs the
passage of the child; also softening or ulceration of the uterine
tissue.
The exciting causes are traumatic, such as blows or kicks,
externally, the maluse of instruments, or improper efforts at
turning.
The idiopathic causes are violent action of the uterine tissue ;
hence, if delivery docs not speedily take place either exhaustion
or rupture rust occur. Hence the danger of giving ergot when
there n.czy be any obstruction to delivery.
Location of Tear. It may occur at any part, but usually near
the cervix. It may be so slight as only to involve the os and
cervix, or large enough to allow the child to escape into the
abdominal cavity. In very rare cases it may only involve the
fibro-muscular tissue leaving the peritoneal covering intact.
Symptoms. The labor pains have been severe and strong, and
when the accident happens they cease abruptly, and she com-
plains of a severe, intense, sharp pain in the lower part of the
abdomen, the presenting part ceases to advance and frequently
an
De Spee
LACTIS RRO RAS OPI GCP IO PE a CIO
Pas nee
f
i
t
i
Wy
i
}
i
96 OBSTETRICS,
recedes, while hemorrhage, external or internal, «sues. If
tho tear has been large enough to allow tie child to escape into
the abdominal cavity it will be felt through the abdominal wall.
The general symptoms are rapid prostration from the shock
and hemorrhage indicated by pallor, feeble pulse, cold extremi-
ties, oppressed breathing, nausea and vomiting first of the
contents of the stomach, and then of coffee ground matter,
clammy ‘perspiration and death.
Prognosis. Formerly thought to be always fatal, and although
these cases were formerly left to nature and death, it has been
observed that some patients recover without assistance, and a
still larger number when they have been judiciously treated.
When the lesion is in the lower part of the uterus, and the child
and placenta are speedily delivered, recoveries are not very
infrequent.
Treatment. Preventive consists in moderating or removing the
predisposing and exciting causes, and diminishing the excessive
muscular action. Be careful in the use of ergot or stimulants
during labor.
Tn cases of dystocia, from impeded uterine efforts, you should
always act early, knowing that the mother is always in danger
of perishing either from exhaustion or rupture of the uterus,
When rupture has occurred the child should be removed at
once by forceps or version, and after removing the placenta see
that the rent does not communicate with the abdominal cavity ;
if not treat the case as after natural labor, giving opium and
stimulants, but if it does open into the abdominal cavity and
there is the least extravasation of the contents of the uterus, at
once perform laparotomy, using all the antiseptic precautions,
care of the uterine wound and toilet of abdominal cavity as in
a case of Caesarean section by the Siinger-Leopold method.
I.
Is
or th
risks
bring
to m:
Th
last t
livin
the ¢
bet we
Th
12
here |
cranic
or ab
to ful
De
prems
is bet
at 361
inches
2.
chron
ascite:
able
menu
If
into
vall.
10ck
2mi-
the
tter,
ugh
been
nd a
ated,
child
very
g the
ssive
lants
ould
hnger
8.
ed at
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ity 5
and
y and
8, at
ions,
as in
OBSTETRICS, 97
D.—OBSsTETRIC OPERATIONS.
I. THR INDUCTION OF PREMATURB LABOR.
Is indicated in cases in which the continuance of pregnancy
or the occurrence of delivery at full term is associated with
risks to the mother or child or both, which may be o'.viated by
bringing pregnancy to a close at a period when the fcetus is able
to maintain a separate existence from the mother.
The child is said to be “viable” if born during any of the
last three months of pregnancy. Of course the probability of its
living will be greater the longer it is retained. When you have
the choice of time in inducing premature delivery, it should be
between the 33rd and 34th week.
The principal indications for the operation are :—
1. A Moderate Degree of Pelvic Contraction. The object
here is to save the child’s life by obviating the necessity for
craniotomy ; or to spare the mother the danger of craniotomy
or abdominal section that might be required if pregnancy went
to full term.
Degree of contracted pelvis in which it is proper to induce
premature delivery to save the child’s life is where the conjugate
is between 24 and 3} inches,
A child at the 28th week may be delivered through a pelvis
whose conjugate is 24 inches ; at 32nd week, through 3 inches ;
at 36th week, through 34 inches, and if conjugate is; over 34
inches it may be left to full term and be delivered by forceps.
2. Diseases which Imperil the Life of the Mother, such as
chronic affections of the heart or lungs, hydramnion, tumors,
ascites associated with dyspnoea, pernicious anemia, uncontrol-
able vomiting, placenta previa, chorea, convulsions, albu-
menuria with excessive cedema.
3. Habitwal Death of Fetus, at a period before which by
‘eile 8
'
ee
98 OBSTETRICS.
experience the fatal ending has occurred. This is often due to
syphilis, in which case both parents should be treated con-
stitutionally.
MODES OF OPERATING.
1. Catheterization of the Uterus. A gum-elastic bougie is
passed into the os and between the membranes and uterus ;
left in situ it usually causes the onset of labor in 24 hours.
2. Puncturing the Membranes. This is.the oldest of all
methods, but is open to the objection to all cases of premature
discharge of the amniotic fluid, viz., tedious labor, absence of
dilating cone, and danger to fcetus from pressure of contracting
uterus on placenta and cord.
3. Mechanical Dilatation of Cervia. Best begun by steel
dilator and then Barnes’ bags. Never use sponge tents.
4, Vaginal Douche. Is a useful adjuvant to the previous
methods.
Besides these there are two methods which are uncertain and
dangerous, viz., the vaginal tampon, india rubber bag or
colpeurynter ; and injections into the uterus.
In the choice of methods take them in the order I have
given them, and the process may he accelerated by ergot,
forceps, or version.
ARTIFICIAL ABorTION. Is justifiable when it offers the only
hope of saving the life of :e mother, and is called for when :—
1, There is incarceration of a prolapsed or retroflexed uterus
which cannot be replaced. .
2. In those diseases of pregnancy which immediately imperil
life, and which have been vainly combated by all the resources
at our disposal.
DUS
es
OBSTETRICS. 99
The operation is performed in ‘the same way as for premature
labor, and as it is..always accompanied by some risk te, the
mother, we should weigh carefully every circumstance of the
case, and if possible have a broeiey practitioner to shure the
responsibility.
It has been condemned as immoral, and iilegal, but it is im-
possible’ to admit! that there’ can’ be any immorality’ ‘in -per-
forming an operation to give a chance of ‘saving the lite! of \a
woman, when by wmeglecting to perform’ it there is almost a
certainty that both herself and child may perish.
DO. THE FORCEPS.
Is a steel instiz:ment which may be termed a pair of artificial
hands, adapted to the form ‘and size’ of the child’s: head, which
when applied, may be used in. safely and, efficiently accomplish-
ing labor when difficult or otherwise impracticable. It is.one
of the most valuable of obstetrical instruments and while it
shot tens the mother’s 8 sufferings, it ‘aves the life of the child.
It ne cinentadl fay ey Dr. Gikasheulain, who kept it fur several
years a secret in the family, and. in.,|672) thus wrote, “My
father, brothers.and myself; (though none. else in Europe as I
know,) have, by, God’s blessing/and our own. industry, attained
_to.,and., long; practiced .a; way. to, deliver, women; in, this, case
without, any, prejudice to; them or their, infants, though. all
others (being obliged, for, want,.of .such an expedient, to use
the common way) nig or must endanger, if nob Agi gal one or
‘POuh’ with hooks! 8 <i7oq | eT
There are three varieties of forceps, the short, the long, re
‘the akisitradtion. * The’ forceps consist of handle; shank, “blade
and lock. The blade has a cephiilic and a’ pelvic curve!” They
may be used at the superior strait, in the excavation, r at the
inferior strait.
}
i]
oe
K4
|
iy
r i
hae
: he
HT
et Hi
i it
tip
ee]
et |
ae
ak
a
1
Cue
i
ue
i
bab
rae:
4
if.
:
100 OBSTETRICS,
They may be used as compressor, tractor, and lever.
The indications for the use of forceps are : —
1, Whe 1 the ordinary forces of nature are insufficient to over-
come the vbstacles to delivery, such as rigidity of parts, con-
| i: tracted pelvis, large head, inertia, etc. a
Nee tion
Byte 2. When speedy delivery is demanded in the interests of or 0
{ ea mother or child, as in puerperal convulsions, Ȣcidental hemorr- cent
E.: hage, placenta preevia, ete.
| ) The conditions essential to safety in their use are :— rs
a 1. The os must be dilated, or dilatable. of t]
a 2. The membrane: ruptured. me. ¢t
befo1
i, *. 3. The rectum and bladder empty. tion:
Perec 4. The pelvis of sufficient size to admit the passage of the
Bes child. 1.
me es to reé
_g Mode of Application. Patient is placed on back, forceps oiled, ther
‘ ¢ warmed and disinfected. Take lett’blade in left hand, and hold- of ec
a ing it like a pen insert it between the child’s head and the fingers
7 of your right hand, which are inserted into vagina to protect (a
soft parts of mother. The right blade is inserted in same way tion
and the instrument locked. Then make traction in axis of assis
pelvis, and in primipara remove the blades when head stretches
the perineum. . The traction should bo steady and not oscilla- (5.
tory. Chloroform may be used or not. hand
| They are applied to sides of pelvis and not to sides of child’s ih
! head.
They should be applied during the intervals of the pains and SI
traction made when the pains come cn. finge
|
OBSTETRICS, 101 |
|
III. VERSION, OR TURNING.
er- 4
ore Is the altering of an unfavorable into a favorable presenta- |
tion, by changing the posture of the child in utero so that one \
of or other extremity of the foetal ellipse shall be brought to the |
rr- centre of the pelvis, and then assisting delivery. |
You should always by a careful examination be satisfied of a
the necessity of the operation ; apprise some judicious relation |
of the characier and necessity of the operation ; the os should q
be dilated or dilatable ; if possible the operation should be done i
before the membranes are ruptured, and if the uterine contrac-
tions are powerful give chloroform to diminish them.
ca 1. Cephalic Version. Is useful when it is only requived
to rectify a faulty presentation, but it is not applicable when
ed, there are complications which call for rapid delivery, as prolapse
ld- of cord or placenta previa or contracted pelvis.
Pr's
ect (a). By EHaternal Method. By external abdominu: manipula-
ay tion the head is brought into position, and held so by an
of assistant until it engages, or else by pad and bandage externally.
bes
a- (b). By Combined Method. (Braxton Hicks’). Introduce left |
hand into the vagina, place right hand on outside of abdomen i
to make out the position of the fvus and direction of heed and !
, feet. q
Ind Should the shoulder present, then push it up with one or two : f
fingers in direction of feet. This will bring down the head
towards the os, whe it may be received on tips of fingers.
‘The head will play like a ball between the internal and external
“hands, and can be piaced in almost any position at will, ii
aay ZS
Se
.
ae
ot a
; ¥
2
102) OBSTETRICS, |
2. Podalic Version. Is indicated where cephalic version
would be too difficult, or in faulty pr esentations of the head and
face, in prolapse of cord, some cases of placenta previa and
accidental hemorrhage, and i in contracted pelvis.
(a). Lined ur Corabinat Method. (Braxton Hicks.) A precise
knowledge of the foetal; position is essential.
Two or three fingers aré passed through the cervix, the pre-
senting, part is pushed upward, the external hand making
pressure in the direction to push down the breech.. The two
hands thus make. the extremities of the ellipse move in opposite
directions, the, movements by which this is affected being a
combination. of continuous pressure and gentle impulses or taps
with the finger tips. on the head or shoulder, and a series of
half sliding, half pushing impulses with the palm of the hand
outside,,, These manipulations are conducted during the inter-
vals: between; the. pains.
This operation is one of the most important contributions to
obstetrical practice during the present century, but requires
the membranes intact or at least just evacuated, and the pains
not ‘suficient to cause ccntraction of uterus upon child.
“b): Thternal Method. This is the operation which was
usualiy referred to under the head of turning, and before the
invention of the forceps was oftener done than at present.
‘The patient is placed upon her back and put under an
aneesthetic. The hand and arm are bared, disinfected, oiled,
and passed into the uterus during the interval of a pain, and a
foot or leg is seized and brougiit down, while the other hand
externally on the abdomen, sieadies the uterus and assists in
the rotation of the child. When a pain comes on desist,
and then during interval proceed, using caution and the utmost
gentleness.
OBSTETRICS. 103
on It is a good plan, if it be a shoulder presentation, and an arm
nd protrudes, to tie a tape around the latter to use afterwards
nd in drawing down arm during delivery, and_preventing it becom-
ing engaged with the head. It will help also to tie a tape
round the leg to assist in traction.
ise
There is more danger in this method than in Hicks’, because
the hand has to be introduced wholly into the uterus, which
re- endangers the mother from septicemia, shock and the risk
ng of lacerating the uterus.
vO
te ; ‘IV. CRANIOTOMY.
ee aay BO ;
ps Consists in perforation of the child’s head, diminution of its
of size, and its delivery. It is solely done in the interests of the
ad mother.
Y- Indications. In deformed pelvis, where the conjugate
diameter is between 27 and 1} inches ; in obstruction by irre.
| movable tumors, or cancer; in rare cases of rigidity of the os
oe or cicatrices ; in dangerous conditions of the mother, as eclamp-
e ° ° . at
Hy sia, calling for. rapid delivery where the use of the forceps or
dy version is not sufficient to meet the case; and in difficult
labors where the child is dead or impacted.
as Signs of a dead child. Absence of heart sounds, cessation of rk Atte
he signs of pregnancy, the patient feels lighter, and the move- },', uxsae.
ments of the child cease ; by digital! examination the cranium
feels flaccid and the bones movable under the scalp.
in
d The Operation of Craniotomy. The patient is placed upon
2 | the back, and chloroform administered to prevent pain and save
d her feelings. Complete dilatation of the os is not necessary.
in The bladder and rectum must be evacuated. The perforator,
it, or Smellie’s scissors, are plunged into skull, withdrawn and
st introduced again so as to make a crucial incision. They are
then passvd down to the medulla so as to destroy the life of ‘| r
104 OBSTETRICS,
the child, since if it is delivered quickly it may cry, even if
some of the brain substance has been evacuated. In some
cases the brain substance may be washed out with a
syringe. Then the craniotomy forceps may be employed to
break up the skull, being careful not to injure the soft parts of
the mother by spicula of bone. To extract the child the blunt
hook may be inserted into the foramen magnum or traction
may be made with the craniotcmy forceps.
Cranioclasm is a modification of craniotomy, where after
using the perforator the cranioclast, which is simply a large and
powerful craniotomy forceps, is introduced xne blade between
the scalp and the skull, and the other insi . he skull, so that a
larger portion of the bone may be crushed, or a firmer hold takua
to make traction, _
Cephalotripsy is another modification of craniotomy, the best
instrument beine ‘hatof Braxton Hicks, which consistsof a power-
ful pair of forceps having only a slight pelvic curve, and a
screw to make powerful compression. The advantage in this
instrument is that the skull may be crushed completely within the
scalp, and thus avoid injury to mother’s soft parts by spicula of
bone, and the head may be so diminished as to pass through a
comparatively small pelvis, while a firm hold to make traction
is effected. Simpson’s basilist is also used.
V. EMBRYOTOMY,
Is applied to those operations on the trunk of the child, which
are designed to diminish its volume and resistance.
Indications. In extreme pelvic contraction ; in foetal mal-
formation ; in neglected shoulder presentation, where version is
impossible or cannot be performed without endangering greatly
the life of the mother.
1. Exenteration is the opening of the abdomen or thorax,
and the removal of the contained viscera. It is most commonly
indica
easy,
the pe
It i
hand
possib
2.
presen
done b
the ne
string
movem
Is a
mother
walls,
I ndi
the cor
tumors
Ccerous «
mother
Oper
to prov:
are the
controll
the nati
Form
| difficult;
wound <
as the §
German
where p
Cases,
OBSTETRICS. 105
indicated in shoulder presentation where decapitation is not
easy, as in extreme pelvic contraction with the head high above
the pelvis.
It is performed by using the perforator so as to admit the
hand and then removing the viscera, after which it may be
possible to seize the feet and turn.
2. Decapitation is to be performed in neglected shoulder
presentations where the neck can be easily reachud. It may be
done by drawing down the prolapsed arm and cutting through
the neck with a blunt scissors ; by Braun’s decollator ; or by a
string passed round the neck which is cut through by a sawing
movement. ;
VI. CHSAREBAN SECTION.
Is an operation by which the foetus is removed from the
mother by an incision made through the abdominal and uterine
walls.
Indications. In extreme degrees of pelvic contraction, where
the conjugate diameter is under 2 inches ; in cases of solid
tumors which encroach on the pelvic space ; in advanced can-
cerous degeneration of the cervix ; and it is permissable if the
mother is moribund and the child is known to be alive.
Operation. It should be done after dilatation of the os so as
to provide a tree outlet for the uterine discharges, the pains
are then more strong, frequent, hemorrhage is more efficiently
controlled, and there is more chance of the child being alive and
the natural tissues uninjured.
Formerly, the operation was an exceedingly fatal one, the
difficulty arising from secondary hemorrhage at the uterine
wound or from septicemia, but by the modern method, known
as the Singer-Leopold operation, the record now, especially in
Germany, is a most brilliant one, it being even asserted that
where promptly conducted it is safer than craniotomy in some
cases,
So ae
Seperate area tetera:
patos “a: = I eg ee
“ A ———— nl ———— ~—
eR ARN I eee a TEI A SS awe
*
106 OBSTETRICS.
The bladder is emptied and an incision is made through the
abdominal wall carefully in the linea alba from below the
umbilicus to just above the pubis, an assistant steadying the
uterus and preventing the escape of the intestines. The uterus
is then incised, avoiding the fundus and cervix, the membranes
are ruptured through the os and the child is extracted as rapidly
as possible, the placenta and clots are removed, and the wound
in uterus is now sutured by deep interrupted silver wire
or silk sutures, which include all the tissues but the decidua, and
should be 4 an inch apart. The peritoneal surface is then
closely stitched with silk, the peritoneal cavity sponged out, es-
pecially Douglas’ pouch, the abdominal wound closed with cat-
gut and treated as after an ovariotomy.
The operation should be conducted on strict antiseptic princi-
ples. The operation should be performed as early as possible,
and the patient should be examined and disturbed as little as
possible previously. The internal and external genitals should
be washed with a sublimate solution (1: 2,000).
Hemorrhage is checked by manual compression or by elastic
ligature.
In order to avoid the risks incident to the operation, and in
certain selected cases, two operations have been designed to this
end :
VII. OVARO-HYSTHRECTOMY.—(Porro)
This consists in Cesarean section, plus removal of the uterus
and ovaries. The operation is precisely similar until the
removal of uterus, when a constrictor is applied, the uterus and
ovaries removed, the stump is mummified with cautery and
percloride of iron and treated by the extra-peritoneal method.
Thi
incisit
cervix
Ope
Poupa
outsid
superic
directo
with a
wards |
bladder
obturat
upon tl
this inc
injure t
is then
right il
remove
lhjected
the fistu
abdomir
otomy.
I. oc
By 6“
from lab
l. Th
eye, the
disturba
are all e
the seve
OBSTETRICS. 107
the VIII. LAPARO-EL YTROTOMY.—(Thomas.)
ane This consists in avoiding a peritoneal and uterine wound by
can incising the vagina and removing the child through the os and
cervix.
nes
‘aly Operation. <A slightly curved incision is made parallel to:
nee Poupart’s ligament on the right side, from 13 inches above and
ae outside the spine of the pubis, to one inch above the anterior
and ig Superior spincus process, cutting layer by layer upon a hernia
han director. An assistant holds back the peritoneum and intestines
ee with a warm napkin, another draws the uterus vigorously up-
ag wards and to the left ; while another holds a catheter in the
bladder in the natural position. A long wooden plug or
obturator is inserted into the vagina and the latter is cut into
inci- upon the obturator by the thermo-cautery ora red hot knife, and
ible, this incision is then torn with the fingers carefully so as not to.
le aS = injure the urethra in front or too far backwards. The catheter
ould is then removed, the uterus tilted and os drawn towards the
right iliac fossa, the membranes ruptured and the child is
jain removed by traction, version, or forceps. Then the bladder is.
injected with a little warm iwilk to see if it is injured, and if so.
the fistula is stitched up with catgut. Then the vaginal and
d in abdominal wounds are stitched up and treated as after ovari-
) this otomy.
E.—Diseases oF CHILDBED.
I. CONVALESCENCE AND ITS DISORDERS.
By ‘“ puerperal state” is meant the condition during recovery
emeaeiese ee a a a eee ete re
renee mercer aaa Aiea ta ee a oo GTDC TP rare ww -
beans from labor. q
; 1. The Nervous Shock. The sudden alteration of the |
and @ °° the diminished or increased sensibility of the brain, the
nd. disturbances of respiration and circulation, the exhaustion, etc., '
are all evidences of the shock, which is usually in proportion to-
the severity of iue labor and the susceptibility of the patient.
>
mt
rsesnssatanpienstiuartemeitit
satan
‘
108 OBSTETRICS,
It is one of the circumstances which indicates the necessity
of keeping the lying-in patient quiet, and as free from all
sources of excitement as possible. After labor the most perfect
quiet should be enjoined, the room should be slightly darkened,
and no person but the nurse, and a few members of the family,
admitted, while little talking and no whispering should be al-
lowed.
The horizontal posture should be strictly enforced and the
patient allowed to sleep.
2. The State of Circulation and Respiration. There
is usually rapidity of the pulse during the second stage of labor,
and after delivery it falls to normal ora little below and so
continues for a day or two until the secretion of milk is estab-
lished. The temperature and respiration follow the same course.
A distinct chill often follows labor, but ir 10t serious, and only
indicates a nervous influence.
When the pulse remains quick and full, instead of sinking,
after labor, beware of some complication.
3. The State of the Uterus and Vagina. After
‘delivery the uterus contracts firmly to the size of a child’s head,
but shortly relaxes slightly and then contracts, this process
having the effect of gradually diminishing the size of the uterus,
until about the 8th or 10th day it is small enough to descend
into the pelvis. The normal size and condition of the uterus and
cervix are not attained until from six to eight weeks after
‘delivery. This is effected by the transformation of the muscular
fibres of the uterus into molecular fat which is absorbed into
the vascular system of the mother. Should this involution be
interfered with as by premature exertion, disease, or perhaps
neglect of lactation, it often remains bulky and the foundation —
for subsequent uterine disease ‘is laid. Immediately after
‘delivery the uterus weighs 33 oz., at the end of a week 16 0z.,
and its cavity measures 54 inches; at the end of a fortnight it
‘weighs 12 oz., and its cavity measures 44 inches.
Af
abras
Th
called
gener:
They
the ap
bound
tinued
that a
Sho
the li
corrug
patche
is rais
The v
color,
giving
has eve
secretic
blood
leucocy
lar cell:
alkaline
varies i
5. T
plentifu
usually
day, an
sity
all
fect
ned,
ily,
> al-
the
‘here
ubor,
d so
stab-
urse.
only
king,
A fter
lt ead,
ocess
erus,
scend
S and
after
cular
into
on be
haps
ation ©
after
6 02.,
pht it
OBSTETRICS. 109
After labor the vagina is usually hot and tender, and presents
abrasions, but it very soon returns to its normal condition.
The contractions of the uterus are accompanied by pains
called ‘‘ after pains,” which seldom occur in primipara. They
generally begin half an hour after labor and last 30 or 40 hours.
They usually have the effect of expelling clots, are increased by
the pplication of the child to the breast, and are salutary within
bounds. Sometimes they are of great severity and long con-
tinued, giving rise to great distress and preventing sleep, so
that anodynes are required.
Should a post-mortem be made a day or two after delivery,
the lining membrane of the uterus will be found loose and
corrugated, somewhat softened and covered more or less with
patches of decidua. The part to which the placenta is attached
is raised and the surface uneven like a granulating ulcer.
The whole internal surface of the uterus is of a dark ash
color, while the discharge upon it is greenish or brownish,
giving the appearance of a morbid condition of the parts which
has even been mistaken for gangrene.
4. The Lochia. Is the discharge which comes from the
internal surface of the body of the uterus together with the
secretions of the cervix and vagina. At first it is almost pure
blood and clots, then it is mixed with serous exudation,
leucocytes, epithelial cells, shreds of decidua, and fatty granu-
lar cells. About the 9th day it becomes greenish. It has an
alkaline reaction and a peculiar smell, readily decomposes and
varies in quantity, quality, odour and duration.
5. The Secretions. The skin is usually moist; urine
plentiful, and often retained after severe labors. Bowels are
usually constipated. The milk comes usually on the 2nd or 3rd.
day, and the chil. should be early put to the breast.
110 OBSTETRICS,
6. The Diet, Cleanliness, etc. Diet should be light
and nutritious, but not much meat for first few days.
The patient should remain in bed for ten days, for more
mischief arises from premature exertion than from almost any
other cause, and when you remember that it takes from six to
eight weeks for the uterus to regain its natural size, the reason
for prolonged rest will be understood.
Immediately after the expulsion of the placenta, apply a
warm antiseptic pad to the vulva, the external parts having
been washed with warm water by the nurse, and see that this
is attended to twice a day. If the lochia smell in the least
degree offensively, use a vaginal douche of bichloride and car-
bolic acid. The patient should always be visited within twelve
hours of the confinement, and the urine enquired about, for if
it is not passed the catheter should be used, taking every
precaution that it is perfectly clean and aseptic.
Some prefer to use the vaginal douche after every case, and
although it may be unnecessary as a rule, yet in hospital
practice it should be insisted upon, and it is always soothing and
comforting to the patient.
An aperient should be given on the third day.
II. DISEASES OF THE BREAST.
1. Sore Nipples. Causes. The too frequent application
of the child removes the sebaceous secretion, so that when the
skin dries it contracts, hardens and cracks. —
Another frequent cause is nursing a child suffering from
thrush.
Symptoms. The nipples become dry, rough, present: cracks,
and become excoriated, and a serous discharge exiidew! |! Theie
are often deep fissures and even ulceration. The’ pain 4s Often
intense, and it frequently leads to mastitis. ,
» hb Ditter enh
Tr
durin
Fo
after |
tinctu
or un;
while
2.
and ¢
milk,
give r
tions,
to the
occurs
two m
Sym
extent
involve
tensior
quick 1
Afte
tion do
a chill
pointin
Ther
(a).
confiner
to fistul
(6). 2
mon va
breast, :
and alw
light
more
b any
ix to
pasONn
ply a
aving
; this
least
1 car-
welve
for if
every
e, and
pital
ng and
OBSTETRICS. 111
Treatment. It should be prevented by bathing the nipples
during pregnancy with some stimulating lotion.
For sore nipples it is best to bathe them with cold water
after nursing, and then use Goulard’s lotion, or paint them with
tincture of catechu, tincture benzoin co., glycerole of tannin,
or ung. zinci. ox., always using a nipple shield to protect them
while the child is nursing.
2. Mastitis. Cawses. Although the excossive irritation
and congestion which occur at the onset of the secretion of
milk, exposure to cold, mental emotion, etc., are all supposed to
give rise to it, sore nipples furnish, with perhaps rare excep-
tions, the starting point from which the inflammation extends
to the glands either by the lymphatics or lactiferous ducts. - It
occurs more frequently among primipara, and «luring the first
two months after delivery.
Symptoms. Their severity depends upon the depth and
extent of the inflammation. When the gland and fascia are
involved the pain is very severe, as well as the swelling and
tension, and the constitutional symptoms are marked by a
quick full pulse, hot skin, headache, thirst, etc.
After the inflammation has continued some time, and resolu-
tion does not take place, suppuration occurs, being indicated by
a chill followed by perspiration, and locally fluctuation and
pointing.
There are three varieties :
(a). The Subcutaneous. Is the mildest form and may be
confined to the areola. When suppuration occurs, it may lead
to fistulous communication with the lactiferous ducts.
(6). The Glandular or Parenchymatous. Is the most com-
mon variety. The skin becomes reddish over the hardened
breast, and the pain is often severe. There is usually a chill
and always more or less fever.
112 OBSTETRICS.
(c). The Submammary. Is the rarest form aid is usuaily
produced by an extension of the suppurative process from the
deep parts of the gland through the connective tissue between
the gland and the pectoral muscle. The breast is sometimes
lifted up by the pus as on a water-bed. The skin is often not
reddened, but is usually cedematous; the pain is deep seated
and dull; and the constitutional symptoms are marked.
Treatment of Mastitis. The first thing is to take the child
away from the breast, and apply a firma pad and well applied
bandage so as to compress the affected breast ; give a dose of
opium to relieve pain, and a saline cathartic to relieve hyper-
emia. The bandage should be left on for from 24 to 48 hours ; if
done in time the inflammation will be found to have undergone
resolution, and the bandage may or may not need re-application.
If it has been too late and suppuration is imminent, apply hot
poultices until fluctuation is felt, then with antiseptic precau-
tions incise taking care to always cut parallel to the milk ducts ;
wash out the cavity with warm bichloride solution (1-5,000)
and apply a compress of gauze soaked in warm bichloride solu-
tion (1-2,000) under oiled silk. This can be changed twice a
day, but do not use any linseed poultices after the pus has once
been evacuated.
In the submammary variety the incisions should be deeper
and freely made,
3. Defective Secretion of Milk. May be due to lack
of mammary development, extreme youth, or polysarca. These
of course are not amenable to treatment.
Temporary insufficiency may be remedied by nitrogenous
diet, outdoor life, the consumption of a large amount of fluid,
especially milk and gruel, and tincture of iron. Cataplasms of
castor oil leaves are said to be beneficial. Tight lacing, by
depressing the nipples and breast, frequently results in defective
secretion of milk.
I
due
the
thir
\
caus
the
con
resp
prec
we (¢
cian
com!
feve
take
N
‘haps
in re
local
that
of n
and
held
viz.,
retai
distiy
ually
. the
ween
bimes
n not
eated
child
yplied
se of
y per-
rs ; if
rgone
ation.
ly hot
recau-
lucts ;
5,000)
solu-
vice A
§ once
eeper
0 lack
These
yennous
fluid,
sms of
ng, by
ective
‘ OBSTETRICS. 113
4. Galactorrhea. A .0o free supply of milk sometimes
is a source of annoyance, and sometimes after lactation is sus-
pended, a constant dribbling of milk occurs, which is a great
drain on the system.
Treatment. Belladonna, compresses, salines and pot. iodid.
III. PUERPERAL FEVER.
Puerperal fever, or puerperal septicemia, is an infectious fever
due to the septic innoculation of the wounds which result from
the separation of the decidua und the passage of the child
through the genital canal in the act of parturition, (Lusk.)
When one considers the frightful mortality from this single
cause, that “ not fewer than 1 in 120 women delivered at or near
the full time dies within the four weeks of childbed,” and that the
condition is now to a large measure amenable to prevention, the
responsibility is great devolving on anyone who neglects the
precautions necessary to avoid such a terrible scourge. While
we du not hold that in every case of puerperal fever the physi-
cian, or midwife, is responsible by reason of sins of omission or
commission, it is certainly true that as the cause of puerperal
fever has been practically demonstrated, a great revolution has
taken place in regard to its prevention and treatment.
No subject has created more discussion than this, and, per-
‘haps, no subject has given rise to a greater diversity of views
in regard to its cause. Thus some have thought it essentially a
local inflammation producing secondary constitutional effects ;
that it might be due to suppression of the lochia, to circulation
of milk in the blood, or that it was a zymotic fever peculiar to
and only attacking puerperal women. The latter view, still
held by some eminent authorities, is unlikely for several reasons,
viz., the symptoms and lesions have no definite character; a
retained and decomposing placenta gives rise to a disease in-
distinguishable from puerperal fever ; the same although less
9
OO PTR mage
ee ee
TERRE RRS IE
Se ee ee eT ee ee eee
»
°
114 OBSTETRICS,
dangerous may follow an abortion, and it may originate from
various kinds of septic material especially from post-mortems
or erysipelas and scarlet fever. It was in 1850 that Sir James Y,
Simpson published a paper ‘‘ On the Analogy between Puer-
peral Fever and Surgical Fever,” and the researches of Pasteur,
Lister, et, al., laid the foundation for the modern view of
its true nature. It is now held that puerperal fever is identical
with surgical septicemia, and that it is produced by absorption
of septic matter into the system through solutions of continuity
in the generative tract such as always exist after labor. The
septic poison itself need not be specific for just as in surgical
septicemia any decomposing organic material, whether homo-
genetic or heterogenetic, may give rise toit. Thus by one grand
swoop have been demolished the various theories of a diseese
which has been the theme of enormous volumes, and endless
discussions in the past. ‘To-day we stand in the presence of an
enemy whose stength we assume to have measured. The best
obstetricians of the present day hold that we have to deal with
certain micro-organisms whose vulnerability by certain gern mi-
cides will enable us to vanquish the foe. '
Let us see now upon what arguments this view is founded :—
|. It can be proved that septic poisons are capable of pro-
ducing the lesions usually associated with puerperal fever.
Thus a small bit of membrane or placenta if retained within
the uterus after labor will cause offensive lochia, and then
give rise to fever which subsides as a rule with the expulsion of
the offending substance, and the use of disinfectant washes.
Furthermore we find that septic poisons introduced after
delivery produce lesions similar tc chose of, puerperal fever, in
one case causing pyemia, in another partial peritonitis, general
peritonitis, diphtheritic inflammations, etc., depending on the
quality of the poison, the point of entrance, and the resistance
of the invaded tissues.
OBSTETRICS. 115
2, Both puerperal fever and surgical septicemia are diseases
characterized by the presence of bacteria.
It is now a well-estavlished biological law that air and water
are peopled with organized microscopical beings, of a nature
imperfectly determined, but which are generally conceded to
be vegetabie matters called microbes or bacteria, which live and
multiply at the expense of organized matter, causing it to under-
go incessant transformations, and giving rise to fermentation,
putrefaction and septicemia, Thus if we expose fresh apple juice
to the air the species of bacteria which are fond of sugar find a
suitable soil, multiply rapidiy, demanding some of the elements
of the sugar molecule, allow the remaining atoms to arrange
themselves into alcohol and carbon dioxide, and cider results ;
other species attack the alcohol and leave acetic acid in its place,
and vinegar results ; all this constituting fermentation. Again,
when a large wound is exposed to the air those bacteria which
feed on albumenous material, set to work destroying the plastic
lymph which has been thrown out, leaving sulphur-alcohols and
ethers in their track, all this constituting putrefaction, and its
concomitants, inflammation and suppuration. So again if
septiceemia or erysipelas spores are present, the blood becomes
infected, and the result is general septicemia or “ blood
poisoning,”
These bacteria are constantly found present in infected
wounds, and they are also present in puerperal fever in the pro-
portions and groupings that we find them in other diseases due
to putrid infection. They are found to be swarming in the
peritoneal exudation, in the blood, and all the tissues, and in
this way we can explain the protean phenomena of puerpere|
fever, as well as the close relationship which it bears to diph-
theria, and erysipelas, and scarlet fever.
3. The differences between surgical and puerperal septicaemia
are due to structural and physiological d’. .erences in the wounded
ws
116 OBSTETRICS.
surfaces exposed to infection. Thus while there is an analogy
between the exposed stump after an smputation and the
interior of the uterus after delivery, there is this difference,
that in the puerperal state you have to take into consideration
the blood changes induced by pregnaney, the effects of shock
and exhaustion, of hemorrhage, the presence of clots and
decidua in a state of disintegration or decomposition, the ease
with which poisonous matters are absorbed by the wide lymph-
atic spaces, the serous infiltration of the pelvic tissues, the
large size of the lymphatics and veins, and the proximity of the
peritoneal cavity.
Puerperal septicemia may be autogeuetic or heterogenetic.
1. Autogenetic. The blood itself is a fruitful source of
puerperal fever, for after labor the absorption of the products of
“uterine involution gives rise toa large amount of effete material
in the bbood, and this may be increased in amount after exces-
sive muscular exertion and expenditure of nerve energy, the
result of a difficult labor or one long unassisted. Again the
decomposition of retained portions of membrane, or placenta, or
lochia may give rise to it. Again, in some cases exposure to
cold, shock or emotion has been known to give rise to the fever.
In some of these cases where a relatively large amount of
putrid material has been absorbed, death may take place from
a form salled putrid intoxication or sapremia, and in these
case. no bacteria may be found in the blood, and the blood is
not infectious. The reason is that the material has undergone
chemical decomposition or putrefaction, but has not taken on
septic changes ; but if a sufficient time is allowed, the bacteria
will have had time to multiply in the blood and tissues, and we
then have all the ordinary phenomena of puerperal fever. It
must be remembered, however, that in the autogenetic variety,
the poison is generally produced by germs received from the air
or in some way from outside, and therefore that the sanitary con-
nalogy
id the
erence,
eration
shock
ts and
he ease
lymph-
es, the
of the
etic.
irce of
ucts of
aterial
exces-
yy, the
jin the
nta, or
ure to
» fever.
unt of
2 from
these
ood is
ergone
ren on
acteria
und we
er. It
ariety,
the air
ry con-
OBSTETRICS. 117
dition of the house or locality may have a large influence in its
production. Many cases of this kind have been traced to
stationary washstands in a bedroom, which have allowed sewer
gas to gain admittance to the room.
2. Heterogenetic. Includes those cases in which the
poison is due to special contagion, The most dangerous
contagion is that due to some forms of puerperal fever itself.
All cases of puerperal fever are not contagious ; thus a case of
Sapreemia is not, and cases of heterogenetic origin are more or
less contagious according to circumstances.
Puerperal fever may also arise from zymotic diseases, such as
scarlet fever, erysipelas, smallpox, or from post mortem poison,
especially if the patient has died from peritonitis ; and lastly,
from insanitary surroundings such as defective drains and want
of cleanliness.
Pathological Anatomy. The local lesions are very various
and depend on the seat of absorption and the form of the
disease ; thus we have endocolpitis, endomotritis, metritis, para-
metritis, perimetritis, phlebitis, phlebo-thrombosis, and lastly
septicemia proper where death is produced before there is
time for the development of local lesions. The only changes
then found are an altered state of the blood, a staining of the
blood vessels, and a softening and swelling of glandular organs,
such as the spleen, liver and kidneys.
Symptoms. These vary according to the part implicated,
the character of the infection, and the amount and virulence of
the poison.
_ There is usually a distinct period of incubation. The fever
first appears within three days of the birth of the child,
and usually on the third day. After the fifth day an
attack is rare, and at the end of a week the patient may be
regarded as having reached the point of safety. It is usually
“ushered in by a chill, but this may be absent, or there may be
118 OBSTETRICS.
repeated chills which usually indicate pyzmia and phlebitis.
The pulse rises, and may reach 120 to 140. The temperature
rises up to 102° or in bad cases to 104° or 106°. Where the
rise of temperature is gradual, as from the slow decomposition
of something retained within the uterus, the chill may be
absent. When a chill accompanies the rise it may suddenly go
up to 102°. Asa rule the temperature tends to rise progres-
sively towards a fatal issue, but in some of the most virulently
septic forms, especially in purulent peritonivis, the temperature
falls again after an initial rise, while the pulse continues to
become more rapid, and the general condition becomes’
aggravated. The pulse is therefore frequently a more reliable
sign of danger than the temperature. As the patient becomes
moribund, the temperature often becomes subnormal.
The symptoms vary according to the local lesion accompany-
ing it. The milder cases are characterized by inflammations of
serous membranes, mucous membranes, or the results of the
impaction of infected emboli, or secondary inflammations and
abscesses. In other cases the fever is so intense that no appre-
ciable morbid phenomena are found after death. It is this
variety which was so prevalent and fatal in the older lying-in
hospitals, and which was likened to cholera in the severity,
suddenness and fatality of its onset.
The pain and tenderness over the uterus may be slight or
Severe according to the local lesion. As it advances the,
intestines become distended with gas, the countenance becomes
sallow and sunken ; the expression is anxious ; as a rule intelli-
gence is unimpaired to the last ; diarrhoea and vomiting frequent-
ly set in, the latter even becoming coffee ground ; the lochia are
offensive usually, and are soon arrested ; the milk dries up ;
these symptoms last usually a week, the pulse beco ising more
rapid, weak and thread-like, and the patient sinks with all the
indications of profound exhaustion.
tel
itis.
ture
the
tion
be
7 go
TeS-
aitly
ure
to
mes -
ible
mes
OBSTETRICS, 119
Treatment. 1. Preventive. It is not always possible to carry
out all the directions indicated, but when possible you should
endeavour to promote the health of the patient before delivery,
bearing in mind that a woman in low and debilitated condition
presents a more suitable soil for the seed or bacteria of sepsis
to take root and develop. The sanitary condition of the house
and the lying-in room should be seen to, especially as to the con-
dition of the drains, permanent wash-stands, if they exist, and
ventilation. She should have a bath before labor sets in and if
possible a vaginal injection of bichloride solution (1-2,000). She
should never be allowed to suffer too long without the timely
use of forceps, but the greatest care should be used not to cause
laceration or unnecessary contusions. Care should be taken
that the nurse has not been in attendance at any case of
zymotic disease, nor should the physician himself have come
directly from any such case. |
The physician should always wash the hands with coarse
soap, and bichloride solution (1-1,000), using the nail brush, and
applying some antiseptic lubricant before making any vaginal
examination.
By the most rigid antiseptic precautions it may not even be '
necessary to give up midwifery practice while attending a case
of puerperal fever.
After delivery the parts should be washed with bichloride
solution (1-2,000), and a piece of gauze soaked in the same
applied, and over this an antiseptic pad consisting of absorbent
cotton or tow sewed up in gauze, and used instead of napkins.
These are cheaper and more cleanly, for they can be burned after
being a few hours in use.
2 Ourative. We should watch for any elevation of
temperature or pulse after labor, and remember that all cases
of so called milk fever are really mild septicsemia, and treat
them as such. The indications are to neutratize the poison at
Se
rrr = — es
“= er rene oe ry Se ee Pea me ee —
. ’
ne
20 OBSTETRICS,
the point of production and so prevent its causing further mis-
chief, and to adopt measures calculated to enable the patient to
tolerate its presence until it is eliminated or inert.
Pain, if present, should be first allayed by a hypodermic in-
jection of morphia, and a vaginal injection of bichloride (1-2,000)
thoroughly given by the physician himself, Then give quinine,
gr. x., and repeat gr. v. every 3 or 4 hours if necessary. If the
temperature still keeps up use the intra-uterine douche of
bichloride (1-5,000), and if there is any suspicion of retained
secundines introduce the fingers, or blunt curette, ard remove
them. All abrasions should be touched with sol. ferri
persulph. and tinct. iodine equal parts.
Locally hot fomentations with turpentine, especially if there
is a tendency to typanitis, but in other cases Townsend’s rubber
tube coil may be placed over the abdomen and ice water
allowed to flow through it. Ifa purgative is indicated give
castor oil or calomel. After using the intra-uterine douche
introduce a pessary of iodoform gr. 20 or 30. In sthenic cases
fluid ext. veratrum viride may be given in drop doses.
The strength must be sustained by beef tea, broths, egg-
nogg, milk and whiskey.
A convenie’:t solution of corrosie sublimate can be made by
dissolving one drachm of the salt in one ounce of alcohol.
One teaspoonful of this solution added to one quart of warm
water will give almost to a fraction one part in two thousand,
and will be sufficient for each injection. :
IV. PUERPERAL VENOUS THROMBOSIS AND
iAMBOLISM.
' A thrombus is a blood clot formed within a_blood-vessel
during life, and the entire process, of which the thrombus is
. the essential element, is designated thrombosis. The thrombus
is made up of fibrin and corpuscles,
arter:
ently
Th
epith
a Stag
after
the b
mate)
still 1
hemo
Ar
large
ances
E mbc
thron
embo
1.
right
situ,
cause
Ov
thron
clot i
Sy
dysp1
breat
distre
and ¢
most
few c
absor
finite
OBSTETRICS. 121
The causes of thrombosis are an abnormal condition of the
epithelium, a rapid destruction of the white blood corpuscles, or
a stagnation of the blood, and there is always a tendency to this
after delivery owing to the excess of the elements of fibrin in
the blood, and because it is charged with a quantity of effete
material due to involution of the hypertrophied uterus. It is
still more apt to occur in the exhaustion following excessive
hemorrhage.
An Embolus is a foreign body in a blood vessel, usually too
large to pass through the smallest capillaries, and the disturb-
ances resulting from its presence are included under the term
Embolism. Although most emboli are detached portions of
thrombi, any foreign body of suitable size may become an
embolus.
1. Pulmonary Obstruction. A clot of blood in the
right **'e¢ of the heart or pulmonary artery, either formed in
situ, » sarried there from another part of the circulation, is a
cause .: sudden death after delivery.
Owing to the state of the blood and system above described a
thrombus forms in some part of the circulation, a portion of the
clot is detached and is carried as an embolus to the pulmonary
artery where it is arrested.
Symptoms. The patient is suddenly seized with severe
dyspnoea, pain in the precordia, she starts up and gasps for
breath, the face is usually livid or may be pale, there is great
distress, anxiety, and restlessness; she feels that she is dying
and calls out for air ; there is cold clammy skin ; the pulse is al-
most imperceptible, and death usually occurs in afew minutes. A
few cases have been recorded where the clot has not been suffici-
ently large to entirely obstruct the circulation in the lungs,
absorption taking place and ultimate recovery, but this is in-
finitely rare.
0 aan (2 etme eens La oe ee
122 OBSTETRICS.
Cause of Death. It is due to asphyxia: the blood cannot get
to the air to be purified.
Treatment. Almost every case is so rapidly fatal that there
is no time for treatment, but if called to a case, place the patient
at absolute rest, the head lower than the body, to favor the
flow of blood to the brain, and give. brandy, ammonia or sul-
phuric ether, hypodermically.
Emboli sometimes occur in the arterial system and may
become arrested in the cerebral, humeral or femoral arteries,
giving rise to hemiplegia, blindness, gangrene, etc.
2. Phlegmasia Alba Dolens. Is a swelling of one or
both legs, characterized by pain, tension of the skin, brawny
hardness, absence of pitting on pressure, and a shiny whiteness
-of -sarface. It affects the left more frequently than the right
leg, probably because that side of the pelvis is more frequently
‘subjected to pressure and bruising than the other from the com-
parative frequency of right lateral obliquity of the uterus. It
affects multipara more often than primipara, and is very apt to
‘recur. It usually comes on between the 2nd and 4th week after
delivery and seldom subsequently.
Symptoms. It is often preceded by slight pyrexia, then
‘severe pain and tenderness in the groin along the course of the
femoral vein, or in the calf of the leg extending upwards over
the whole limb, and you can often feel the femoral vein hard
like a whipcord. The swelling then spreads and increases in
hardness, which is unlike ordinary cedema or anasarca, for after
it is fully developed it does not pit on pressure, but is elastic
and feels like solid rubber. Its color is pale or sallow and
hence the name “ white-leg ;” it looks also glossy or greasy and
hence the term “ marble leg.” All movement is painful and
voluxtary motion is nearly lost. In about nine days it makes
no further progress, the pain and swelling diminishing.
Pathology. It was at one time thought to be due to arrest of
. ulcer
Tyle
patie
short
phleg
t get
here
tient
the
sul-
may
eries,
ne or
awny
eness
right
ently
com-
5 It
apt to
after
then
of the
3 over
. hard
jes in
after
slastic
vy and
y and
1 and
nakes
“est of
OBSTETRICS. 123
the secretion of milk and its extravasation in the limb, and
hence the term “ milk leg.” The view which is now held is
that it is due to thrombosis of the femoral vein and lymphatics.
(a). Morbid Anatomy. 1. On opening the limb it is found
to be distended with coagulable lymph effused into the cellular
tissue.
2. The vein is obliterated by clots, and the walls are thick-
ened, and of a dark red color, coated with coagulable lymph,
showing inflammation.
3. There are evidences of inflammation of the lymphatics.
(b). Nature of the process. It requires more than throm-
bosis of the femoral vein to account for the hardness and want
of pitting on pressure, and the fact that the tissues are filled
with coagulable lymph and not serum. This can only be
accounted for in one of two ways: either that there exists
obstruction of the ]ymphatics as well as the veins, or that some
toxeemic condition of the blood exists in consequence of which
the fluid poured out is irritating to the tissues, and sets up a
kind of quasi-inflammation, leading to the production of coagu-
lable lymph. Probably both views are true, for that it is of
septic origin is probable, as it occurs in other states such as
.ulcerated cancer of the cervix, and in late stages of phthisis.
Tyler Smith records the case of a physician who attended a
patient suffering from erysipelatous sloughing sore throat, and
shortly afterwards three confinements, each of which had
phlegmasia dolens.
Terminations. It may en: in resolution ; persistent aching
and oedema of the limb; in suppuration, which is rare ; in
relapse with slow recovery ; and there is always danger, by
rubbing, of an embolus being set free and causing pulmonary
obstruction. :
Treatment. Locally, rest in the most comfortable position,
hot fomentations with opium under oil silk, or poultices.
124 OBSTETRICS,
Subsequently gentle inunctions with ung. iodini co., or ung.
hydrarg. c. belladonna are useful.
Medicinally opium for the pain, quinine, tonics, good diet,
and change of air complete the cure.
V. PUERPERAL INSANITY.
When one recollects the excitable and altered state of the
nervous system during pregnancy, partly due to reflex causes,
to disordered digestion and to alterations of the blood, it is not
to be wondered at that the same conditions which give rise to
alterations in character, to loss of memory, to hysteria, or hy-
pochondriasis should sometimes lead to mental derangement. In
some women, again, there exists a hereditary predisposition to
insanity, and the events of pregnancy and child-bed act simply
as the sparks that fire the mine.
The term puerperal mania is hardly correct, as many of these
cases are characterized by melancholy.
From 3 to 5 per cent. of all females admitted into asylums
suffer from puerperal insanity, and at least one out of every
1,000 lying-in women becomes insane. It is equally prevalent
among rich and poor. |
It may for convenience be divided into three forms: that
occurring during pregnancy, after labor, and during lactation.
1. The insanity of Pregnancy. ‘This is the least com-
mon form, usually assuming a form of melancholia, developing
out of the ordinary hypochondriasis of pregnancy, especially in
those of a hereditary neurosis. It usually shows itself between
the 3rd and 4th month, and the suicidal tendency is often well
marked, The prognosis, however, is more favorable than in
any other form.
2. Puerperal Insanity (proper). During delivery and.
at the last part of the second stage, a kind of acute delirium is
iet,
the
uses,
not
e to
» hy-
> In
yn to
mply
these
rlums
every
ralent.
that
ion.
-com-
oping
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tween
1 well
an in
y and.
lum is
OBSTETRICS. 125
sometimes met with just when the suffering is most intense,
while the patient in her agony, if not watched, might injure
herself or her child. This is not really puerperal mania, and
should be rarely seen in these days of anesthetics, but it may
be of importance in a medico-legal point of view.
Causes, There is in nearly all these cases a hereditary taint,
not always insanity, but she may have inherited an irritable,
unstable, or impressionable nervous system. Thus the family
history will often show hysteria, epilepsy, chorea, asthma, or
stuttering, if not actual insanity. Most of these cases are
anemic, and show signs of a sluggish alimentary canal, especi-
ally constipation, and impaired digestion.
Grief, shame, anxiety, and sudden fright, are among the
moral causes, aud some have even held that it had a septic
origin.
Symptoms. It may assume either the form of mania or
melancholia, the former coming on usually within the first three
weeks after labor, the latter not until later. The patient first
appears out of health, has dyspepsia and sleeplessness, is fretful
and anxious, and as the melancholy deepens she has delusions
about her husband and child, and has suicidal tendencies. In
mania there is au intolerance of restraint, irritability and either
unconcern or open hostility to her infant. They often have
religious delusions, and some cases are raving mad, tearing
their clothes and requiring to be restrained.
3. Insanity of Lactation. Is twice as common as the
insanity of pregnancy, but much less frequent than puerperal
insanity proper. The causes are the same, and the form of
melancholia is more common than mania.
Prognosis. More than two thirds of the cases of puerperal
insanity recover. Maniacal cases get well on the average in
from three to six months, while the meloncholic take longer.
*‘ Mania is more dangerous to life, melancholia to reason.”
126 OBS “ICS.
=~
Treatment. Something may be done towards preventing the
disease by improving the health during pregnancy, by warning
the patient and her friends against all irritating mental or moral
influences, and guarding against septic infection during and
after labor, and seeing that the patient has a suflicient amount
of sleep.
With the first sign of trouble the child should be taken
from the breast, liquid food should be administered at regular
intervals, the room slightly darkened, furniture or pictures
which disturb the patient by their associations should be
removed ; if possible a trained nurse should be secured to
administer food, to attend to the bowels and bladder, to keep
the patient covered, and to prevent her doing harm to herself
or others.
If poor, the asylum is the best method of treatment, but if
she can afford it, home treatment is preferable ‘since there is
always apt to be a reproach connected with any one who has
once been in an insane asylum ; ‘“ though the recovery is rapid
and satisfactory, still she has been insane, and this is never for-
gotten by her children. Henceforward there isa certain dread
of what may be in the future a skeleton in the closet, not
mentioned, but always there,” whereas if home treatment is
successful, she will only be thought to have been a little queer,
the confinement wiil account for that, and nothing more will
either be said or thought of it.
Is
peri
M
ing |
Befo
be 1
chilc
their
the «
nutr
and |
occul
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and
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feet,
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wom
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o has
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GYN ZCOLOGY,
GYNASCOLOGY.
Is the study and treatment of the diseases peculiar to women,
and does not usually include those occuring at the puerperal
period,
Most of these diseases occur during her sexual life, z.¢., dur-
ing the period of functional activity of the uterus and ovaries.
Before this she is a child, when her diseases are few and ~ay
be regarded as accidental or developmental, and whe. ae
child-bearing period is over the sexual organs shrivel up and
their function no longer influences the system at large. ‘Towards
the climacteric there is often developed a tendency to morbid
nutrition or degeneration, and hence the frequency of cancer
and fibrc..9 at this time. But even when no tissue changes
occur, at this period various distressing phenomena are met
with which often become pathological. The sexual apparatus.
no longer dominating the system, the balance of healthy action
and reaction being lost, the nervous force not finding its long
accustomed use wanders off ia other paths and often leads to.
nervous disturbances such as neuralgia, hysteria, syncope,
vertigo, convulsions or even insanity. These are merely exag-
gerations of those “ hot flashes,” tingling, numbness, burning
feet, etc., so common to every woman at the change of life.
Most of these diseases, which are infrequent in uncivilized
women, are due to the customs of civilized life. There is first.
the neglect of exercise and physical development. Thus in a.
young ladies’ boarding-school most of the time is taken up in
sedentary study, and the hours of recreation which should
be spent in walking or calisthenics, are employed in music or
painting. This very application leads to excessive develop-
ment of the nervous system resulting in precocious talent,
refined taste and vivacity, but at the same time developing
128 GYN ACOLOGY.
morbid impressibility, feebleness of muscular system, excessive
uterine and ovarian congestion, often resulting in ‘ neuralgic
dysmenorrhea.”
Then again the dress adopted by the “girl of the period,”
and especially the corset, so compresses the abdominal organs
that the muscles become atrophied, and the viscera displaced, the
full play of the abdominal wall and the descent of the diaphragm
are interfered with ; this leads to obstruction of venous blood
and congestion of the pelvic organs. T')> uterus itself being
freely movable is displaced and distorted.
Again, imprudence during menstruation is a frequent source of
disease. A host of women, either through ignorance or reck-
lessness, by ignoring this physiological function, have incited
congestive dysmenorrhea or endometritis, while a word of
timely warning might have gaved them. a life of suffering,
misery or sterility. Imprudence after parturition, too early
getting up, tight bandaging, neglect of injuries occurring during
labor, such as laceration of cervix or perineum, the prevention
of conception, the induction of abortion, and, lastly, habitual
constipation are all sources of uterine disease.
Diagnosis. Manifestly in the study of uterine ; disease one
of the first pre-requisites to successful treatment is a correct
diagnosis. The two principal sources from which information
is to be derived are, Ist, the subjective symptoms as related by
the patient, and 2nd, the objective symptoms as made out by a
physical examination.
In examining any female patient let her begin the account of
her illness in her own way, sud although she may wander from
the point, it will afford you some hints, and give you a clue to
follow out in your subsequent more special questioning.
You should begin by taking a general survey of the principal
Suj
ssive
ralgic
riod,”
rgans
d, the
ragm
blood
being
rce of
reck-
ncited
rd of
ering,
early
during
ention
bitual
ise one
correct
mation
ted by
it by a
sunt of
rv from
clue to
incipal
GSE “he
GYNAECOLOGY. 129
functions, enquiring about the nervous system, the circulation,
and the digestion ; if the bowels are regular, and, lastly, if she is
unwell every month. This will be better than to begin abruptly
with an enquiry about the uterine system, as, especially if the
patient is young and unmarried, she would only be flurried and
annoy you by unsatisfactory or even incorrect replies. Always
follow some systematic plan in your enquiries, such as the +
following :—
| OE Oar ot ee oa ne ere aera CO eee eee ey
lS eek eed wip Wk CHEE OG tude Oe ER ROL plRib RK palierbackee
Married ?
No. of Children. Date of last Confinement.
No. of Miscarriages. Date of last Miscarriage.
Age at first Menstruation. Date of last Catamenia.
How long ill,
Principal symptoms :
sev eeeeeveee eoerevevevpeeeee eevee ee ee ee eee eee ereaeeeeeeeeeeones
Supposed cause.
Present condition :—
Regular. d
A ;
Menstruation ant. a
Duration.
Pain.
Character.
Discharge Amount.
Constancy,
Locality.
Pain Degree.
Character.
10
ea ET ONL NE i Het
tah GON i CAN i A i le eS ID el ance Piensa ste aeae, ~
*
Diewirinns oni,
or 5
130 GYNECOLOGY.
‘ Digital. -
Physical 9
ONIN peculum.
Examination
Sound.
Diagnosis.
Treatrent :
Result.
The symptoms which would chiefly attract your attention to
the pelvic organs are :—a sensation of weight, bearing down or
falling in the abdomen and pelvis; pain in the hypogastric,
inguinal, or sacral regions, darting or radiating pains from the
pubis down the thighs or into the inguinal or hypochondriac
regions, pain on defecation or micturition, dispareunia, difficulty
in walking, going up and down stairs or in sitting down, itch-
ing of the external genitals, leucorrhoea, disorders of menstrua-
tion. In menorrhagia the amount of blood lost is guaged by
the number of napkins changed in a given time, and in leucor-.
rhoea the character of the discharge, whether white, sanguineous,
‘ serous, ropy or offensive, is of importance in indicating the seat
and nature of the affection.
Having thus obtained all the information you can by this
subjective examination, you must, in order to accurate diag-
nosis, make an objective or physical examination of the patient.
A.—Non-INSTRUMENTAL EXAMINATION.
I. EXTEHEENAL ABDOMINAL.
1. Inspection. Loosen the clothing about the waist and
bare the abdomen. See if it is distended ; note its shape, color,
the prominence of the umbilicus, linea albicantes, skin eruptions,
Examine the breasts and areola.
bo s
yn to
yn or
stric,
n the
driac
culty
itch-
trua-
ad by
ucOor-...
eous,
> seat
y this
diag-
tient.
GYNAECOLOGY. 131
2. Palpation. Place the patient in the dorsal position
with the thighs bent up, and with both hands and the tips of
the fingers paw each region in order. By this means you can
detect tumors arising from the uterus, ovaries, kidneys, liver,
spleen, omentum, etc.
The resistance of the abdominal muscles is often an obstacle,
and in doubtful cases it may be necessary to give chloroform.
The presence of fat, inflammation or fluid in the abdominal
cavity may also render the examination difficult. You must
also be careful not to mistake for pathological growths certain
normal conditions, such as a pregnant uterus, a distended
bladder, and an overloaded rectum. The latter is usually soft,
pultaceous and displaceable.
t
3. Percussion. The patient should be examined in this
way on her back, on both sides, and while sitting up. The
extent and attachment of a tumor may be detected by its area
. e e e e ®
of dulness. Typanitis and ascitic fluid may also be made out.
4. Auscultation. The fcetal heart sounds, uterine souffle,
and friction sound may be heard. A uterine souffle without
heart sounds is either pregnancy with a dead child, or a uterine
fibroid. Ovarian cysts have no soufile.
Il. INSPECTION OF THE EXTERNAL GENITALS,
This need not be done as a routine practice, but may be
required to detect chancres, mucous patches, condylomata,
labial ebscess, tears of the perineum, external piles, protrusions
of the vaginal wall, presence of varicose veins, cedema of labia,
condition of the hymen, presence of caruncule myrtiformes.
Always examine the secretions,
132 GYNZCOLOGY.
II. DIGITAL EXAMINATION.
b
1. Vaginal. The dorsal position is preferable, but the al
lateral, the knee-elbow or genu-pectoral, and the erect positions tl
are sometimes resorted to. Digital examination is rarely ¥
necessary before puberty, because the diseases calling for it
seldom arise before the onset of menstruation, and in fact are tl
in the large majority of cases the resv!* of parturition. If
possible this examination, especially in the young and unmar-
ried, should be deferred until we try the effect of medicine and pi
hygienic measures. If these fail after reasonable trial, a vaginal . tk
examination should be proposed and gently insisted upon. A WW
vaginal examination should not. be made during the menstrual
flow, not because it is injurious, but because it is unpleasant to
any woman to be handled while she is soiled. You should not
hesitate however to examine when the persistence of a sanguin-
aous flow requires immediate diagnosis and treatment.
Use the index finger well anointed with vaseline, and if the
vagina is very patulous, use two fingers, folding the other
fingers and abducting the thumb. Note the state of the vaginal
orifice, the presence of spasm, whether the hymen is intact, the
walls of the vagina if rough or smooth, the temperature of the
vagina, the cervix and external os and their direction and
mobility. In the posterior fornia, feel for feeces, a retroverted
uterus, blood-clot, inflammation, cystic ovary or extrauterine
foetation ; in the anterior fornix for normal uterus or one
enlarged from pregnancy or fibroid ; and in the lateral fornices
for prolapsed and cystic ovary. The cervix may be long with
pinhole os indicating congenital sterility, or a cicatricial con-
tracted rigid os indicating acquired sterility. The os may be
patulous, indicating abortion; or soft and pulpy, as in pregnancy;
or lacerated ; or may present an ulcerated surface, as in cancer-
ous disease.
GYNECOLOGY. 133
2. Rectal. Before making this examination, see that the
bowel is evacuated by a purgative orenema. This examination
should be made if the symptoms point to disease there, and then
the retro-uterine tissues and the posterior wall of the uterus
are more accessible through the rectum. Strictures, polypi,
cancer, syphilitic ulceration, retro-uterine tumors, etc., tay
thus be detected. Digital eversion of the mucous membrane of
the rectum will often be useful in detecting piles, fissures, etc.
3. Vesical. As this requires dilatation of the urethra, the
patient should be prepared for it, and should have an anes-
thetic. The interior of the bladder and even the mouths of the
ureters may thus be felt.
IV. BIMANUAL BXAMINATION.
This is a very important mode of examination, and consists
in placing one hand upon the abdomen, while the finger of the
other hand is in the vagina. You can thus feel any motion
imparted to the hand by the interior examining finger, and
determine the shape and position of the uterus or ovaries, or
the presence of tumors. For this purpose the dorsal position.is
best.
The recto-abdominal and the recto-vagino-abdominal modes
of examination may also be resorted to.
B.—INSTRUMENTAL EXAMINATION,
1. The Speculum. Is notalways necessary, for the finger
may have given you all the required information, but never
omit this mode of examination if it will give any further insight
into the case, and if it is not otherwise contra-indicated. It
should never be used in acute inflammations, or cancer, rarely
in menorrhagia, and still more infrequently in young virgins.
f
There are three varieties, all the rest being modifications of
134 GYNACOLOGY,
these :—1. The Cylindrical or Ferguson’s. 2. The Bivalve or Ww
Cusco’s, and 3. The Duckbill or Sims’. or
1. The Cylindrical Speculwm is usually made of glass, silver
plated inside, or of hard rubber, or of white porcelain. It may
a oh be used for the application of caustics which might act upon a
metal instrument, but it is now nearly discarded.
2. The Bivalve Speculum is the most useful for genera] pur- ar
poses, being more durable, and giving a much better view of
the cervix and vagina. It may be introduced either in the
lateral or dorsal positions, although the latter is usually prefer-
able.
3. The Duckbill Speculum is absolutely essential to the
proper study and treatment of many of the diseases of women.
It acts upon the principle of admitting air to the vagina, so
that as the woman lies in the lateral prone position, the weight
of the viscera assists in giving a good view of the parts, and
the cervix can be seen in a natural position, being movable,
and the os with its lips uneverted. The disadvantage of this
instrument is that an assistant is required usually to elevate
the superior buttock, or to hold the anterior vaginal wall for-
ward with a depressor. Operations on the cervix and vagina
are only possible by means of this speculum.
ke « ms ws
EAE tn a CR Be NL Zi pith 3 cera Baoan 2
eee
pein Ae
ares
II. THE UTERINE SOUND.
This was the invention of Sir Jas. Y. Simpson, and consists
of a flexible copper rod electro-plated, 12 inch long, and gradu-
ated 24 inches from the point.
rare 9 reer
Before using the uterine sound, you should ascertain by the
digital and bimanual methods, the true position of the uterus,
and if there are no contra-indications, pass it gently and care-
fully into the uterus, holding it like a pen. Be careful not to
use any force lest it cause abrasion of the mucous membrane
MOT seine dieetdiccoore re See aapicaesapcactaonaanats Sue banaewe
or
GYNECOLOGY. 135
with absorption of septic material which might result in para-
or perimetritis.
Uses. It is used to ascertain
1, The length of the uterine cavity.
(a). Which may be lessened by super-involution or atrophy.
(6). Which may be increased by subinvolution, hypertrophy
and uterine fibroids.
2. The direction of the uterine axis.
This is to detect retroversion, anteversion, and lateroversion.
3. The relation of the uterine to the cervical axis,
This is to detect anteflexion and retroflexion.
4. The presence of stenosis or atresia of the os.
5. The mobility of the uterus.
6. The condition of the endo-metrium or mucous membrane
- of the uterus.
7. It may be used as a means of treatment as in dilating
atresia, in rectifying an anteflexion or retroflexion, or in
replacing a retroversion.
Contra-indications. It should never be used during the
menstrual flow ; during an acute inflammatory attack of the
uterus or ovaries ; in cancer of the cervix or body of the uterus ;
nor if the patient has missed a period.
The sound may be used in combination with the bimanual
method to more accurately determine the fundus of the uterus,
or to diagnose tumors of the uterus from ovarian cysts. |
Other Instruments. A long flexible pure silver probe is often
very useful as in cases of atresia where the uterine sound could
not be inserted, or between a tumor and the uterine wall to
determine its presence and extent.
The tenaculwm or hook is used to draw down and steady the
136 GYN ECOLOGY.
cervix, to approximate the edges of a lacerated cervix, or to
catch up sutures during operations in the vagina. <A vulsellum
is simply a double tenaculum.
The dilator is a steel instrument for opening the os uteri, and
is infinitely preferable to sponge tents, which should now be
discarded entirely for antiseptic reasons.
The curette is an instrument shaped somewhat like a spoon or
scoop, and used for the purpose of removing by scraping off
certain pathological tissues. It was invented by Recamier in
1846, and is now very much used, and to the successful gyneeco-
logist is indispensable. It is used in uterine hemorrhage and
erosions of the os, and as a means of diagnosis by examining the
scrapings. Inuterine hemorrhage which has resisted all medicinal
treatment, a cure may often be effected by dilating the os and
using the curette to remove fungus degeneration of the uterine
mucous membrane, or small polypi, or adherent placental villi.
In any manipulations about the uterus you must bear in mind
to always avoid them during pregnancy, and at any time do not
use any unnecessary violence, During the puerperal state all
operations are to be avoided, except of course immediate
closure of a perineal rent, since there is such a great tendency
at that time to septic infection, favored also by the dilated con-
dition of the pelvic veins. Lactation does not interfere with
operations except in so far as anesthesia, excitement, and
probable suppuration may affect the quality of the milk, and of
course the woman is at that time in a somewhat enfeebled con-
dition.
In advancing age women should be taught that while not in
itself serious or dangerous, this period has been found by
experience to be especially favorable to the development of
malignant disease, and that therefore the slightest disorder of
menstruation or leucorrhal discharge may be the first indica-
r to
lum
and
be
nor
off
rin
£eCO+
and
the
inal
and
rine
villi.
nind
o not
> all
liate
ency
con-
with
and
id of
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yt in
| by
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ar of
lica-
GYNECOLOGY. 137
tion of serious or fatal disease, and that therefore an examina-
tion should be firmly insisted upon. Age does not contra-indicate
operation since ovariotomy has been successfully performed
after the age of 70.
The peculiar situation of the uterus, the large networks of
blood-vessels, the loose character of the surrounding connective
tissue, and the proximity of the peritoneum render manipulation
of the uterus difficult, and at times dangerous. While the
uterus has the name and reputation of being the most patient
and the toughest organ in the body, it or its surroundings will
at times respond very unexpectedly and severely to the slightest
manipulation. While one uterus will bear with impunity the
application of fuming nitric acid to its internal surface,
another will react severely to the introduction of the uterine
sound, and a very simple operation may light up serious peri-
tonitis. The pre-existence of chronic or subacute peritonitis is
more apt to be followed by an acute attack if the uterus is
irritated, and hence it would contra-indicate all operative
' measures.:
SPECIAL DISEASES.
A.—DISEASES OF THE VULVA.
I MALFORMATIONS.
At first a depression takes place in the external skin, during
the process of development, which gradually deepens until it
communicates with the allantois which is not yet separated
from the bowel. At the point where the allantois emerges
from the bowel, the perineum protrudes forward separating the
vaginal cloaca into two parts, the sinus urogenitalis in front,
and the anus behind. Into the sinus urogenitalis opens the
most dependent part of the allantois, which becomes narrowed
down to form the urethra, and the vagina is formed by the
a
Ln ap ine aR a Pk ie TS a gE Rl ER a
138 GYNECOLOGY.
lower ends of the two Miiller’s ducts, Now should develop-
ment be arrested at some stage of this process, the result will
be the various forms of hypospadias, epispadias, hermaphrodi-
tism, or atresia of the anus.
II. VULVITIS.
Causes. Inflammation of the vulva may result from injury,
irritating discharges as fron; want of cleanliness, or gonorrhea,
and may result in ulceration, abscess or phlegmon. It may occur
in scrofulous children, and it is often the result of worms.
Symptoms. Itching, pain, redness, swelling, and increased
secretion. Pruritis or itching is often described as a separate
disease, and it is often a sign of diabetes.
Treatment. Cleanliness and lotions of plumbic acetate with
opium, or if itching is marked, potassic cyanide solution and
carbolized compresses are useful.
iI. NEW GROWTHS.
Papillomata or warty growths are common, are usually
syphilitic and are best treated by chromic acid locally, and
hydearg. bichlor. internally.
Lupus is found sometimes in strumous subjects.
Primary Cancer is rare.
Cysts of the vulva arise from the obstructed glands of
Bartholini, and are treated the same as cysts elsewhere.
IV. RUPTURE OF THE PERINEUM.
Is not uncommon ; it usually occurs in primipara and seldom
in multipara, and its occurrence is not surprising when you
consider the immense distension of the parts during labor.
Causes. 1. Owing to the Mother. Very powerful
bvelop-
t will
bhrodi-
injury,
rrhea,
y occur
8.
reased
pparate
ep with
on and
usually
ly, and.
nds of
seldom
en you
rr,
owerful
GYN ECOLOGY. 139
uterine contractions may too suddenly expel the child before
the perineum hs had time to expand, or there may be defi-
ciency in the tone of the perineal structures, or a straight sa-
crum, or there may be preternatural narrowing of the pubic
arch interfering with extension so that distension of the pe-
rineum is greater.
2. Owing to the Child. Unusual size of foetal head, or
great breadth of shoulders may cause it ; or face presentations.
3. Owing to the Physician. Malpractice or meddle-
some midwifery, faulty support of the perineum or the unskil-
ful use of the forceps may cause it. In wise and practised
hands the forceps are among the most valuable resources of the
obstetric art, and are capable of preventing the very damage
which they are frequently charged with producing.
Its Nature and Effect. Rupture of the perineum may be of
varying extent, from simple tear of the fourchette, which occurs.
in every primipara, to the extent of tearing the sphincter and
recto-vaginal septum.
Much difference of opinion exists in regard to the importance
of the perineal body, which is a triangular wedge of fascia and
areolar tissue, elastic and dense, situated between the lower
part of the vagina and the rectum.
By some its functions are thought to be :—
(a). To sustain and prevent prolapse of the anterior wall of
rectum which would drag down the cervix.
(b). To sustain and prevent prolapse of the posterior wall of
vagina which would allow rectocele.
(c). Upon the posterior vaginal wall rests the anterior, and
on this the bladder, and against the bladder the uterus all of
which are dependant on it for support.
(d). It preserves a proper line of pi jection of the contents.
140 GYNECOLOGY.
of the bladder and rectum, and thus prevents the occurence of
tenesmus, which is a frequent cause of pelvic displacements.
The effect of a ruptured perineum depends on its degree,
When a rupture extends through the recto-vaginal septum the id
: : ) the r
muscular attachments of the pelvic floor being torn, the uterus et
looses its support and descends. agi
may
Air is thus often admitted into the vagina and causes “ flatus In
vaginalis,” and cystocele-and rectocele are frequent, These You
effects lead to difficulty in walking, irritability of the bladder, signs
indigestion, nervous troubles and loss of control of the sphinter chars
ani with its consequences. The
; , of fw
Treatment. 1. The Immediate or Primary Oper- ;
, j : maki
ation. The perineum should always be examined after ing |
delivery, and if a tear exists it should be at once bathed with
bichloride solution (1-1,000) and from one to three or four
‘silver wire sutures introduced.
Even if it is through the sphincter it should be stitched at
once, and give it a chance, for if it fails no harm is done.
2. The Secondary Operation. (a). Partial Rupture.
The patient is etherized, the mucus membrane freshened with
curved scissors, and the parts brought together with silver
wire sutures. The bowels should be kept open every day, and
the sutures left for a week or ten days.
(b). Complete Ruptwre. The operation is similar, but great
care is taken to freshen the edges of the wound through the
sphincter and tear in recto-vaginal wall, and the first suture or
two should begin by taking in this part, completely surround-
ing it and the tear in anus. The other sutures are applied as
in a partial rupture.
bnce of
ts.
egree.
im the
uterus
‘ flatus
These
ladder,
hinter
Oper-
l after
d with
or four
shed at
upture.
od with
_ silver
ay, and
t great
gh the
ture or
rround-
lied as
GYNECOLOGY. 14}
B.—DIsEASES OF THE VAGINA.
I MALFORMATIONS.
You may have a double vagina, or it may open directly into
the rectum, or it may be a cul-de-sac leading up to a rudimen-
tary uterus, or an imperforate hymen may exist, or occlusion
may occur from sloughing after delivery.
Imperforate Hymen sometimes gives rise to retained menses,
You would suspect such a condition if puberty has arrived, and
signs of being unwell are present without any sanguineous dis-
charge, especially when there are pains of a forcing character.
The abdomen soon becomes tender and there is a feeling
of fulness in the pelvis and frequent desire to micturate. On
making an examination there is felt to be a bulging fluctuat-
ing tumor at the vulval orifice of a deep red color.
Treatment. The hymen should be punctured antiseptically
and washes used for some days, there being danger of admitting
air and setting up septic peritonitis.
IT, VAGINISMUS.
Ts a painful cramp of the sphinter cunni which prevents the
entrance of any body into the vagina. It gives rise to dispar-
eunia, a speculum examination is impossible, and even a digital
examination can hardly ever be borne.
It may be caused by inflammation, fissures, or a thickened
hymen, or it may just be due to nervous spasm. mas be Angled
Treatment. If temporary, as often happens in the newly
married, advise temporary discontinuance of the sexual act.
If due to inflammation or fissures, treat these, and if it is simply
due to nervous spasm etherize the patient, incise the vaginal
edges, dilate thoroughly with a bivalve speculum, introduce a
.
—EE
142 GYN ZACOLOGY.
tampon of absorbent cotton well smeared with vaseline and
leave it in for 24 hours.
III. COLPITIS.
Inflammation of the vagina is characterized by pain, heat,
increased secretion, and frequent and painful micturition.
Causes. Foreign bodies, as a tampon or pessary, left in too
long ; but the most common cause is gonorrhceal infection.
Treatment. Remove the cause and use a wash of plumbic
acetate and borax, or if gonorrhceal, introduce a speculum,
apply a solution of silver nitrate (gr. xxx—oz. 1) and apply a
tampon of cotton smeared with vaseline, which is left in for a
few hours, and then a wash of borax should be employed
frequently,
IV. NEW GROWTHS.
Myomata occur sometimes and may be submucous or poly-
poid.
Cancer is always secondary to that of cervix.
Encysted tumors are due to retention of cyst contents and are
best treated by snipping out a piece of their wall.
V. FISTULA. :
There are several forms of these, such as vesico-vaginal, recto-
vaginal, utero-vesical, and utero-vagino-vesical. A consider-
ation of one will suffice for the rest.
Vesico-vaginal fistula is an accident liable :to occur as a result
of child-birth, and until a recent period such a case was doomed
to a life of seclusion and despondency, besides being compelled
to live in an atmosphere reeking with the smell of decomposing
urine. In 1852, J. Marion Sims invented an operation, the
elem
lum,
Of
these
long
mala
pess
2.
phag
Sy
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and
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—aA §
der
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, heat,
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in for a
mployed
or poly-
and are
il, recto-
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a result
doomed
mpelled
mposing
ion, the
GYNACOLOGY. 143
elements of which consisted in the use of the duck-bill specu.
lum, silver wire sutures, and a self-retaining catheter.
Causes. 1. Traumatic. The cause of 90 per cent, of
these cases is a tedious labor; the foetal head pressing for a too
long time upon the soft parts gives rise to a slough. So the
maladroit use of forceps or perforator, a badly fitting or rough
pessary, or a stone in the bladder may give rise to it.
2. Pathological. Cancer extending from the uterus, or a
phagedenic chancre may cause it,
Symptoms, A history of retention of urine -ollowing a
tedious or instrumental labor, needing the use of the catheter,
and in a few days the urine is passed involuntarily, causing
excoriation of the nates. An examination will reveal the
fistula.
Operation. Lateral position and Sims’ duck-hill speculum,
under ether; pare the edges for 3 to 4 an inch around the
opening, not including the mucous membrane of the bladder.
Silver wire sutures are introduced 1s of an inch apart, the
first suture at the middle of the wound, and they must not
include the vesical mucous membrane as it will give rise to
tenesmus ; perfurated shot is applied over the wire and clamped
—a self-retaining catheter should then be inserted, and the blad-
der washed out daily with boracic solution, and the sutures re-
moved on the 8th day.
C.—DISEASES OF THE UTERUS.
I. DISORDERS OF MENSTPRUATION.
Menstruation is the function popularly spoken of as the
«“ monthly period,” the “courses,” “turns,” or “the being
unwell.” It begins from the age of 14 to that of 17,
depending on the climate, education, and mode of life. We
have seen that it is accompanied by certain changes in the
.
ae DERRINGER FEARING A ARTE SAO sect aL Ae eee minrnaagedeveonineet-on scale
- a
144 GYN ZCOLOGY.
individual, both bodily and menval. A knowledge of the
healthy function is therefore necessary in order to understand
its disorders. Its duration is 5 days, its amount 24 oz, it
recurs every 28 days, it continues to recur periodically until
about 45 years of age when the climacteric usually occurs, and
i during a period of about 30 years it only ceases normally dur-
i ing pregnancy and lactation.
f
|
For the proper performance of this function three elements
must exist in a perfect state of integrity :
| 1. The ovaries, uterus, and vagina must be perfect in form
and vigor.
2. The blood must be in a normal condition.
3. The nervous system, governing the relations between the
uterus and ovaries, must be unimpaired in tone,
Any influence disordering one or more of these elements may
check ovulation, the great moving cause of the function; will
prevent th> degree of sympathetic congestion necessary for
rupture of the uterine vessels, or will oppose the flow of blood
which has been effused.
‘ 1. Amenorrhcea. There are two distinct forms; first,
where the menses have never appeared, and second, where
having continued regularly for some time they have ceased.
(a). DELAYED MENSTRUATION.
(a). From congenital malformation.
(i). Absence of uterus or ovaries.
(iz). Stenosis of uterus or vagina.
(ia) Tmportope ie Hispa
da OA
(B). Functional Here there is an absence of e above
causes, and it is usually due to some constitutional disorder, as
phthisis, chlorosis, Bright’s disease, etc.
as
a4 Pu Nat
3 —— ¥ Pe tyra ©
unat
time
I
wit]
peri
and
a
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tom
the
of the
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0z., it
until
rs, and
ly dur-
ements
n form
GYNECOLOGY. 145
(b). SUPPRESSED MENSTRUATION. It may be simply irregular
as to time, quantity or quality, or it may be completely
arrested. Sometimes it is replaced by a uterine leucorrhea.
“Or And POM AA ‘
Causes. Sudden cold, bodily or mental shock, fevers and
severe disease, change from country to town, etc.
Symptoms. The amount of disturbance varies very much,
but most fr-quently there is headache, fever, severe pain in
abdomen and head, and frequently hysteria. Sometimes these
symptoms are relieved by vicarious menstruation or uterine
leucorrhea, or it may ‘ast for months with abating disturbance
of the system, but more or less ill-health.
2 . . Cee . a ’ : is
Be careful to distinguish it from pregnancy. } (1...»
Treatment. In delayed menstruation if the health is
unaffected it is best to wait, being careful to find out in due
time if there is any congenital defect present.
In suppressed menstruation the hot hip-bath and foot-bath,
with hot drinks, and an aloetic purge just before the expected
period are often all that is required. Tien a mixture of iron |
and aloes, or Blaud’s pills, with exercise and fresh air.
2. Dysmenorrhcea is menstruation accompanied by pain
just before, during, or after the period. The character of the
pain and the nature and severity of the accompanying symp-
toms vary according to the constitution of the individua!; hence
there are several varieties, viz. :—Neuralgic, congestive, mecha-
nical, membranous, and ovarian,
(a). Neuralgic. Usually occurs in young girls or in sterile
married women, and in those of a nervous, delicate constitu-
tion. The pain is usually severe and frequently in paroxysms,
but unaccompanied by fever.
(b). Congestive. Usually occurs in those of a sanguine or
plethoric temperament, and usually in married women, The
11
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146 GYNACOLOGY.
face is flushed, there is usually fever, and severe pain in the
back, and aching in the limbs. The pain usually ceases after
the flow is established, and the latter is often profuse. An
examination shows enlargement and congestion of the cervix
and frequently abrasion. The bladder frequently sympathizes
and the breasts are tender. :
(c). Obstructive. Is caused mostly by atresia of the os or
retroflexion, and is readily detected by an examination. The
pain precedes the tlow, and there is usually sterility.
(d). Membranous. Where the superficial layer of the mucous
membrane of the uterus is cast off as a coherent triangular sac,
or else in shreds of a more or less firm consistence. It is
accompanied by intense uterine pains like those of labor. Be
careful not to mistake it for abortion, where you would find the
villi of the chorion, large decidual cells, and epithelium under-
going fatty degeneration. Its true pathology 1 is unknown, and
its prognosis is unfavorable. Merrell, 2 etm * La
4
}
(e’. Ovarian. ‘These are cases where you can eliminate any
uterine or periuterine cause, and where there is not merely a
neuralgic condition, but the ovaries can usually be felt enlarged,
congested, tender or prolapsed ; they are often accompanied by
epilepsy ; and the pain precedes the tlow by several days. The
prognosis is usually bad.
Causes of Dysmenorrhea. Cold during the menstrual period,
sudden shock, mental emotion, constipation resulting in sluggish
portal circulation, displacement of the uterus, endometritis, )
atresia, and peri or para-metritis.
Treatment of Dysmenorrhea. 1. During an attack. Mor-
phia, hot brandy, or even pees oe ae ey’ fomentations
locally, and hot baths. “pert, “#4 re"
2. To prevent a return, This depends on the cause. [If it is
n the
after
An
ervix
thizes
os or
The
ucous
1 sac,
It is
. Be
id the
inder-
1, and
e any
rely a
arged,
ed by
The
eriod,
iggish
tritis, ,
Mor-
ations
f it is
GYNECOLOGY. 147
neuralgic, strengthen the patient by tonics, exercise and fresh
air, and lessen general and local irritability.
If due to congestion, treat ally by depletion and applica-
tions of iodine or the hot vaginal douche, and generally by
saline aperients. If obstructive, dilate thoroughly, under
chloroform if necessary, with a steel dilator ; or if due to retro-
f<ion treat that. If membranous, give Donovan’s solution
internally, and iodoform pencils to ut .us. If any of these
resist all treatment, especially the ovarian form, it may be
necessary to remove the tubes and ovaries.
3. Menorrhagia is applied to excessive menstruation,
while ‘‘metrorrhagia” is applied to uterine hemorrhage or a
flow occurring during the interval of the menstrual periods.
The period may occur too frequently, or it may be too
copious.
There are two forms met with in practice which are, strictly
_ speaking, degrees of the same disorder, but the division is a
convenient one.
(a). The flow is of natural quality, but the quantity or freq-
uency of recurrence is increased.
It occurs in the unmarried sometimes, especially in young
females who have to work hard, running up and down stairs, or
using the sewing-machine.
Symptoms. Those of a continuous debilitating discharge,
exhaustion, anzemia, languor, giddiness, pain in the side, and
disorders of digestion.
(6). The flow is excessive, mixed with clots, and there is
often subinvolution and displacements of the uterus. This
form is confined usually to married life, and generally in those
of a phlegmatic temperament and a constitution impaired by
disease,
148 GYN ZCOLOGY.
Symptoms. The symptoms are more intense, and on exam-
in :tion the cervix is large, open, and often eroded.
Pathology of Menorrhagia. (a). Any condition which
induces a state of active or passive congestion of the uterus or
its lining, such as subinvolution, displacements, fibroids,
ovaritis, lacerated cervix and plethora.
(6). Anything which creates a solution of continuity of its
lining, such as fungoid degeneration.
(c). Any, growth having a vascular connection with the
uterus, such as fibroids, polypi, products of conception, and
cancer.
(d). Any dyscrasia ui the blood, such as scurvy, chlorosis or
uremia. There are cases where there is an absence of all these
causes, and they might at present be called functional.
Diagnosis. It should not be comfounded with abortion or
the climacteric—a careful examination should always be made
after medicinal treatment has been fairly tried, and it may even
be necessary to dilate the os and thoroughly explore.
Treatment. In the simple variety, rest; a generous but
unstimulating diet, and a mixture of sulphuric acid and zinc.
sulphate, with alum injections may be all that is necessary. . If
this fails, seek the cause and treat it secundum artem. Never
give iron in menorrhagia.
Leucorrhcea, commonly called ‘“ the whites,” is a symptom
and not a disease.
1, VaainaL Leucorrua@a, (a). Acute. Is characterized by a
white creamy discharge of acid reaction, accompanied by heat,
soveness, fulness, smarting or pain, weight and bearing down in
the vagina with a frequent desire to micturate. On examination
the mucous membrane is red, swollen and tender. The prinei-
pal causes are cold, violence, high living and excessive sexual
indulgence. AN
wn in
ation
rinci-
exual
GYN ECOLOGY. 149
Diagnosis. It is difficult to distinguish it from gonorrhea,
but in the latter there is more:bladder trouble, the glands in
the groin are usually enlarged, and the history of the case will
assist.
Treatment. Injections of plumbi acet. or borax and tonics
will often be sufficient. In gonorrhea wash out the vagina
with hot water, introduce a speculum and swab out thoroughly
with a solution of silver nitrate (gr. 30—oz. i.) and introduce a
tampon of absorbent cotton smeared with vaseline.
(b). Chronic. It is very common, as the vagina is exposed
to so many sources of irritation. The causes are nearly all
those of menorrhagia.
There is usually pain in the back and symptoms of a debili-
tating discharge.
Treatment. Injections, tonics, and the removal of the cause.
2. Uterine Levcorrua@a. Is characterized by a thick glairy
alkaline discharge, which on examination with speculum is seen
to ooze from the os uteri. It occurs often as .vicarious of
menstruation, or at the climacteric, and is frequent in chlorotic
subjects and after abortions.
It is usually of a chronic character, gives rise to back-ache
and general debility. Its causes are similar to those of menorr- .
hagia.
Treatment. Seek the cause, which is most frequently
endometritis, and treat the local affection, while at the same
time give tonics and constitutional treatment.
Sterility. The desire for family, either to perpetuate the
name, or for the descent of property, or the mere love of pro-
geny, is so strong an instinct that with every other blessing
many are miserable because they have no children. There can
be no wonder then that you may often be consulted to remove
the cause.
T
41
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ay)
i4)
a)
Hii
aii
ag
4
i
;
:
o}
i}
H
1
|
150 GYN ZCOLOGY.
Causes. Bearing in mind the physiology of conception it
will be easy to comprehend why barrenness or sterility should
so often occur.
1, Anything which prevents the entrance of the semen into
the uterus.
(a). Absence of uterus or vagina.
. Imperforate hymen.
. Vaginismus.
. Atresia of vagina or uterus. .
. Cervical endometritis.
(f). Fibroids or polypi.
(g). Displacements.
2. Anything which prevents. the production of a healthy —
ovum. :
(a). Chronic ovaritis, or cystic degeneration of the ovary.
(>). Parametritis and perimetritis.
(c). Absence of the ovaries.
3. Anything which prevents the passage.of the ovule into
.‘the uterus. ,
(a). Stricture of the fallopian tubes.
4, Anything which destroys the vitality of the semen or pre-
vents fixation of the impregnated ovum.
(a). Endometritis.
(6). Leucorrvhea, and gonorrhcea and geek in the male after
marriage, infecting the woman. 3
(c) Membranous dysmenorrhea.
(d). Menorrhagia,
(e). Abnormal growths, such as fibroids.
ion it
hould
into
althy —
ry.
> into
r pre-
after
GYNECOLOGY. 151
(f). Subinvolution.
If all these causes are found to be absent, then examine the
husband and see if the organs of generation are healthy and
sound, and examine the semen microscopically for spermatozoa,
and enquire for a history of syphilis.
Married women, who are sterile, usually regard it as a
reproach to their womanhood ; sterility is therefore a cause of
much unhappiness, so that it is well to inform the patient that
a. large proportion by appropriate treatment may become
fruitful. |
Treatment, consists in removing the cause if possible.
Il. MALFORMATIONS.
These can only be understood in connection with the history
of development. During the 4th and 5th week of intrauterine
life, the Wolffian bodies are situated on each side of the verte-
bral column, and are the primordial or temporary kidneys.
Their efferent channels communicate with the kidneys, but in
the female are of no importance pathologically. From the
lower angle of the Wolffian body a ligament extends to the
inguinal region which developes into the round ligament of the.
uterus. At the median margin of the Wolffian body is the
germinal gland, which becomes the ovary in the female, the
testis in the male. From the anterior surface arises a cord,
at first solid, called Miiller’s duct, which becomes vf the greatest
importance in the female. Both efferent channels of the
Wolffian body, as well as the two mutually united Miiller’s
ducts, insert themselves into the lower end of the urinary
bladder at the point between the urethra above and the
urogenital sinus below. While the Wolffian body is retarded
in its growth into the parovariuin, and the function of secreting
urine is assumed by the kidneys, Miiller’s ducts continue to
o GYN ACOLOGY.
develop, and then join together probably at the point where
later the vagina is united to the cervix uteri. The septum
between the two ducts then disappears so that a common canal
arises, but the upper ends remain separate and begin to diverge.
The upper extremity of the ducts becomes fimbriated, the next
part becomes the fallopian tube itself, and the lower portions
unite to form the uterus, which soon increases in size to form
the fundus, and below, the vagina. The inguinal ligament
approaches the upper edges of the uterus constituting the round
ligament ; the germinal glands, becoming the ovaries, sink down
to the sides of the uterus, and at the point where the vagina
and urogenital sinus join a fold arises which hecomes the
hymen.
Now if Miiller’s ducts fail to unite, we have bicornuity ; if
they unite externally but the septum fails to disappear, we have
bilocularity ; if one of Miller’s ducts is absent or only partially
developed, we have unicornity ; or though joining and losing
the septum in some portion there may be arrested development,
we may have the uterus in an infantile state or rudimentary, or
entirely absent.
* III. STHNOSIS OF OS UTERI.
Normally the os tince is transverse and about two lines in
length. Stenosis or narrowing of the os may be congenital,
constituting ‘‘ pinhole os,” which is usually a cause of! sterility
and frequently conjoined with a long conical cervix, or it may
be acquired by the use of strong caustics. It usually gives rise
to dysmenorrhea or sterility, and is readily diagnosed by an
examination.
Treatment. Dilatation with steel dilator, and in some cases
the use of stem pessary afterwards, Mi vei Oo
where
eptum
canal
verge.
e next
brtions
> form
rament
round
k down
vagina
es the
ity ; if
e have
irtially
losing
pment,
lary, or
nes in
enital,
erility
it may
es rise
by an
@ Cases
GYN ZCOLOGY,
1V. INFULUAMMATION.
1. Endometritis is an inflammation of the lining mem-
brane of the cervix uteri. It may be acute or chronic.
(a). Acute. Is a concomitant of acute metritis, indistinguish-
able from it, and treated in the same way.
(b). Chronic. Is a very common affection.
Pathology. The mucous lining of the cervix is disposed in
folds and ridges known as the arbor vite, covered by columnar
epithelium and studded with numerous villi. Between the folds
are the glands or follicles of Naboth, about 10,000 in number.
When inflamed this membrane is swollen, and hyperemic ;
the glands, being especially involved, pour out a glairy viscid
mucous which fills up the cervical canal in the form of a tenaci-
ous plug. This often creates abrasion or erosion of the os, and
it was this appearance which used to be called “ ulceration.”
Causes. While there is usually some constitutional predis-
position, as ill-health, scrofula, etc., it is commonly brought on
by exposure to cold during menstruation ; by excessive sexual
indulgence ; injury from sound, tent, or pessary ; parturition,
especially when the uterus has not been completely emptied ;
tumors in the uterine cavity ; uterine displacements, especially
retroflexion and prolapse ; lace ated cervix; attempts at abor-
tion ; and extension of gonorrhea.
Symptoms. (a). Leucorrhea. The secretion is thick and
glairy, of alkaline reaction, and is most characteristic of the
complaint. Owing to the small amount of sensibility of the
cervix, inflammation may be present without attracting the
patient’s attention until leucorrhcea becomes marked.
(b). Menorrhagia. This may frequently lead to anemia.
(c). Dysmenorrhea is frequent. Then there is weakness in
154 GYNAZCOLOGY. .
the back, and pain in the pelvis and loins, digestive and
nervous derangements, sterility and often abortion. After the
disease is established constitutional symptoms become more
marked, nutrition is impaired, she becomes nervous, hysterical,
fretful and despondent.
On examination with speculum the os is usually seen to be
inflamed or abraded, with a thick glairy secretion oozing out
of it. ae spins, b perohe bee Lue
Treatment. , Regulate constipation if present, build up the
general health and combat any diathesis that may be present.
Then dilate, curette, dry and apply iodized phenol, and glycerine
tampon. Then use a vaginal douche of plumbic acetate and
borax every day. In very stubborn cases, zinc alum pessaries
or fuming nitric acid are useful. Never use intrauterine
injections.
2. Acute Metritis. Is an inflammation of the muscular
and fibrous tissue of the uterus. Generally the lining is
affected first, and Thomas thinks acute metritis is merely a
complication of endometritis.
Pathology. The uterus is enlarged, thickened, doughy,
infiltrated with serum, the veins engorged, but the cavity is not
altered in size.
Causes.. Mostly from an extension of inflammation from
the mucous or serous lining of the uterus, and most commonly
as part of the general inflammation produced by absorption of
septic matter during the puerperal state. It may also arise
from exposure to cold at the menstrual period ; from gonorrheal
infection ; or the careless use of the sound or curette.
Symptoms. It usually begins with a chill, and then fever
with more or less general constitutional disturbance. There is
a sense of heat, burning and fulness in the pelvis, and pain in
the |
ment
TI
blad
O1
gasti
swol]
ness
the |
Tl
grad
T
due
state
solut
rem:
Pert
dose
tine
3.
mati
out.
norr
e and
fter the
Pp more
sterical,
to be
ing out
up the
resent,
ycerine
hte and
ssaries
uterine.
uscular
ing is
erely a
oughy,
y isnot
n from
nmonly
ytion of
O arise
rhoeal
n fever
here is
pain in
GYNECOLOGY. 155
the hypogastric and sacral regions, aggravated by every move-
ment of the body or in evacuating the bowels or bladder.
There is usually nausea, vomiting, diarrhcea, tenesmus of the
bladder and rectum,
On examination there is tenderness on pressure in the hypo-
gastric region ; the vaginal walls are hot and dry ; the cervix is
swollen and any movement of it causes pain ; there is tender-
ness in all the fornices. The bimanual is almost impossible for
the pain. Avoid the use of the sound.
The acute symptoms usually terminate in a week, resolution
gradually taking place, or else it runs into the chronic form.
Treatment, Remove the cause, especially if supposed to be
due to septic poison. Thus if it occurs during the puerperal
state the uterine cavity should be washed out with bichloride
solution (1-5,000), and if any portions of placenta or secundines
remain they should be removed by the finger. or blunt curette.
Perfect rest and morphia to ease pain with quinine in gr. vy.
doses every 4 hours, and locally hot fomentations and turpen-
tine stupes, with hot vaginal injections.
3. Chronic Metritis. Is not correctly a chronic inflam-
mation at all, but consists in an increase of connective tissue
out of proportion to that of the muscular fibre which remains
normal or but slightly increased in quantity, ahd is dependant
upon long-continued hyperemia. It resembles cirrhosis of the
liver, and might in fact be called “ cirrhosis of the uterus.”
“Subinvolution of the uterus” one of its principal causes,
cannot be diagnosed from it, and is treated in the same way.
Pathology. Like cirrhosis of the liver, at an early stage the
uterus is enlarged, hyperemic and soft, but ‘ater on it becomes
indurated, anemic and hard. There is an increased amount of.
connective tissue and a diminution of muscular fibre.
156 GYNACOLOGY.
Causes. (a). Of Chronic Metritis, the result of Subinvolu-
tion. Retention of portions of placenta, membranes, or blood
clots ; lacerated cervix ; pelvic inflammation after labor ; rising
too soon after delivery ; non-lactation; and repeated mis-
carriages.
In the process of normal involution there are two factors, the
fatty degeneration of the muscular fibre and the removal of the
products of this degeneration. The enlargement of subinvolution
is due to the substitution of connective tissue for the products
of this degeneration.
(6). Of Chronic Metritis, the result of repeated congestion.
Displacements of the uterus ;. pressure of distended bladder or
tumors upon the uterus; endometritis ; the too free use of
caustics, and excessive sexual indulgence.
Symptoms. She usually dates her sufferings from a previous
confinement or miscarriage. After such an occurrence she feels
weak, has pains and weakness in the back, a feeling of weight
and bearing down in the pelvis, and a want of power in the
limbs. Then there is leucorrhea and irregular menstruation,
which may lead to frequent abortions, and shortly to ster-
ility.. After a time the constitutional disturbances become
marked and urgent. 5
On examination the uterus is felt to be enlarged, especially
the cervix and os. The uterus is freely movable and its cavity
is enlarged so that the sound passes more than 24 inches, and
there is usually endometritis.
Treatment. First seek the cause and remove that, such as
endometritis, lacerated cervix, fungoid degeneration, displace-
ments, etc. Then rest, local depletion by glycerine tampons,
the application of tinct. iodine co., and hot vaginal douches.
&, J.4. f+ ¢€Internally ergot, quinine and nux vomica. If these means
oi
S-
AG,
Neyer
fail, trachelorrhaphy often acts well.
W
local
injw
of g
natu
free
injec
suck
tion,
mati
binvolu-
r blood
; rising
pd =mis-
ors, the
hl of the
olution
broducts
gestion.
adder or
B use of
previous
she feels
f weight
r in the
iruation,
to ster-
become
specially
iS cavity
hes, and
such as
lisplace-
am pons,
louches.
» means
- junction of the sacrum and coccyx.
GYN ZCOLOGY. 157
What is the influence of pregnancy and parturition on the
local conditioas of chronic metritis! In many cases it is
injurious, but it may be so conducted as to accomplish a degree
of good which can be obtained in no other way. Thus a
natural delivery free from laceration, a prolonged decubitus
free from sepsis, perfect cleanliness by means of vaginal
injections, ergot and quinine to secure tonic contractions,
suckling of the infant, and a careful return to ordinary exer-
_ tion, are the means which may bring about a complete transfor-
mation.
V. DISLOCATIONS OR DISPLACEMENTS
Include alterations of curvature as well as of position, hence
we have flexions and versions.
In the recumbent woman the vagina lies almost horizontally,
the concavity being upwards. Between it and the uterus lieg
the plate-shaped empty bladder and immediately upon it the
uterus, so that in the normal state there is no free space between
the uterus and the bladder. The fundus of the uterus is
directed towards the symphysis pubis, and its upper border is
on a level with the plane of the superior strait. The cer.
vix or vaginal portion of the uterus is on a level with the
As there is usually a
slight bend at the internal os, the cervix points somewhat
downwards. Behind the uterus the rectum descends on the
left, but often extends beyond the middle line, so that in frozen
sections the part above the anus is situated entirely on the
right side. Now it is of particular importance to remember
that the uterus is freely movable and not absolutely fixed, and
that
1. The uterus in toto is displaceable in all directions.
2. It may be moved in such a manner that the upper longer
arm of the Jever,—the body, imparts motion to the lower
158 . GYNAECOLOGY.
smaller arm,—the cervix, in the opposite direction, and inversely
wne cervix to the body.
3. The uterus may be bent upon itself to a slight degree.
Thus the uterus, being held relatively in position somewhat
loosely between the floor of the pelvis below and the intestines
above, as well as by its ligaments, is pushed backwards by a
distended bladder, forwards by a distended rectum, sinks on
standing, is elevated in coition, and can be moved about by
digital examination. As loug as the pressure from above and
the resistence from below are physiologically balanced, so long
the uterus lies in normal position, the ligaments do not imme-
diately enter into consideration,—but if the pelvic floor relaxes,
or the pressure becomes excessive from above, the uterus will
change its position and drag on its ligaments and on their
attachments. You should not put too much importance upon
slight variations, for unless marked or persistent they are not
pathological, and you may sometimes be surprised to find on
examining a patient, a well-marked flexion which had not made
its presence felt by any symptoms.
This however is exceptional, and is due to the fact that
flexions and versions in themselves give rise to no symptoms
primarily, the symptoms arising secondarily, and being due to
1. Interference with the functions of menstruation, concep-
tion or pregnancy.
2. Chronic metritis or endometritis producea by the displace-
ment.
3. celvic cellulitis and peritonitis accompanying the
displacement and frequently causing it.
Causes of Displacements in general. 1. Influences which
increase the bulk and weight of the uterus, such as congesticn,
pregnancy, fibroid tumors, subinvolution and u;pertropuy.
2. Influences which weaken or displace its supports, such
,
Ne
as d
exces
tight
tumc
1.
angle
ing |
and |
metr
Sy
signs
pelvi
deran
D:
the |
posit
soun:
suspi
7)
and
astri:
adjus
infla:
healt
pessa
crad]
2.
of th
that
or ac
abou
to hg
tory
versely
"ee,
mewhat
estines
ls by a
nks on
out by
ve and
80 long
imme-
elaxes,
s will
their
B upon
are not
find on
yt made
+t that
nptoms
le to
concep-
isplace-
y the
=)
which
esuicn,
y.
, such
;
GYNACOLOGV. 159
as defective nutrition, local or general ; enfeebled health,
excessive intra-abdominal pressure, violent muscular effort,
tight lacing, wearing heavy clothing, pressure of abdominal
tumors, etc.
1. Anteversion. The uterus is straightened, the normal
angle at the internal os becoming obliterated and the os point-
ing backwards. It occurs physiologically in early pregnancy,
and pathologically when the uterus is enlarged through chronic
metritis.
Symptoms. There are none per se, but there are usually the
signs of chronic uterine or pelvic inflammation, such as pain in
pelvis, difficulty in walking, micturition and defecation and
derangements of the digestive and nervous systems.
Digital examination detects the os directed backwards, and
the body of the uterus is felt through the anterior fornix. The
position is felt by the bimanual method and verified by the
sound, but be careful in the use of the latter if there is the least
suspicion of pregnancy.
Treatment, Keep the patient in bed, regulate the bowels
f and bladder, elevate the hips and use an injection of some
astringent, or a tampon of glycerine and tannin, and a carefully
adjusted abdominal belt. Any complication such as hyperemia,
inflammation or abrasion should be attended to, and the general
health built up by tonics. Do not be in any hurry to use a
pessary, but if these means fail, you can insert a Graily Hewitt
cradle pessary.
2. Anteflexion. Is an exaggeration of the normal flexion
of the uterus, and is more frequent in nullipare for the reason
that it is a frequent cause of sterility. It may be congenital ;
or acquired, which is usually due in delicate ill-nourished girls
about the age of puberty to tight lacing, or heavy skirts, or
to habitual constipation ; or it may be the result of inflamma-
tory changes behind the uterus.
160 GYNACOLOGY.
Symptoms. (a). Dysmenorrhea. ‘This may be explained in
two ways :—
(a). The obstructive or mechanical theory, held by Simpson
and Sims, that the flexion causes a narrowing of the uterine
canal obstructing the free exit of the menstrual blood which is
retained, coagulates, and causes the uterus to painfully contract
to expel the clots. While it is objected to this theory that the
blood is not always clotted, that it is often in small quantity,
and that the pains have not always the distinctive character of
labor pains, yet if not the correct view it is difficult to explain
the great benefit derived from various modes of treatment based
upon it.
(8B). The congestive theory, held by the Germans, that the pain
is not due to the bend in the uterine canal but arises from the
resistance which the muscular tissue of the uterus offers to the
hyperemia. In normal cases the tissue yields to the distending
vessels, but when the uterus is bent upon itself there is an
obstruction to the flow of blood, the mucous membrane cannot
swell up as it normally does at the menstrual periods, there is
thus undue vascular tension and compression of the nerve end-
ings in the uterus, causing pain. There is always in this
condition of anteflexion more or less density of tissue, the result
of chronic inflammation which makes the tissue more dense and
resisting, and the increased vascularity at these times causes
pain just as in periostitis where pain in the affected limb is
increased by its becoming warm in bed.
(b). Sterility. Is due to the same cause.
Then there are dysuria, dyspareunia, leucorrhcea, and often
menorrhagia.
Diagnosis. ‘By digital examination the cervix is felt to be
high up, and the os looks downwards ana forwards, while the
body of uterus is felt in the anterior fornix forming a distinct
cannot
there is
rve end-
in this
1e result
nse and
3 causes
limb is
id often
lt to be
hile the
distinct
GYNECOLOGY. 161
angle. This is verified by the bimanual, and the sound must
be bent before it will pass up to the fundus.
It must be differentiated from myoma of the anterior wall of
the uterus, in which case the sound passes normally, while the
finger in the vagina detects the increased thickness of the
anterior uterine wall, its hardness, irregularity and want of
symmetry, and the increased bulk of the whole uterus.
Treatment. Pelvic inflammation if present should be first
attended to, and cicatricial bands stretched by the daily use of
well applied glycerine tampons. These cases require patience,
perseverance and skill.
(a). The occasional introduction of the uterine sound. This
should be done a few days after menstruation, and if its pres-
ence does not irritate you can make a wide sweep of the handle
and place the uteris in a state of retroversion for a short time
daily.
(6). The intrauterine stem pessary, with or without previous
dilatation with steel dilator. Keep the patient in bed for a few
days so as to watch its effect and withdraw it if there is any
irritation.
(c) Should these means fail, divide the cervix and keep it
open with an intrauterine glass plug.
3. Retroversion. The whole uterus is directed back-
wards.
Tt is caused by sudden strains or blows ; by carelessness after
labor, as at that time from its weight and laxity of attachment
it is always more or less retroverted or retroposed for a few
days ; or by inflammation behind the uterus causing adhesions.
The symptoms a-> che same as those of retroflexion.
Diagnosis. The cervix is low down, and the os looks down-
wards and forwards. By the bimanual the fundus is found to
pee ¢
162 GYN ECOLOGY.
be absent from the anterior fornix, but can be felt through the vis
rectum, and the sound passes in directly backwards. mi
Treatment. Remove any existing inflammation first and
then if there are no adhesions replace the uterus by the biman-
ual or by the sound, or combine with these the genu-pectoral
an
position, and retain it in place by a Hodge, Albert Smith, the
Thomas, or Greenhalgh’s pessary. th
4. Retroflexion. Besides being turned back the normal be:
angle is reversed.
This displacement is one of the most common and most por
important that you meet with. Besides being placed backwards | |
upon itself so that the fundus lies in Douglas’ pouch, its size is
increased, the cervix is directed downwards and forwards.
Causes. The dorsal position and too tight bandaging after
confinement, or the patient rising too soon while the uterus is és
large and heavy and its supports lax and weak, give rise to it. fins
It may however be congenital. Gi
Symptoms. There is usually much greater discomfort than soft
‘in retroversion.
(a). Weakness in the back, which may in some cases amount
to actual pain.
(6). Symptoms of chronic perimetritis.
(c). Painful defecation.
(d). Leucorrhea. This is due to chronic endometritis, the
displacement causing passive congestion.
(e). Dysmenorrhea is not so frequent as in anteflexion.
(f). Menorrhagia, which is due to chronic endometritis and
obstruction.
(g). Sterility, which is due to the altered position of the cer-
bh the
and
biman-
bctoral
Smith,
ormal
most
wards
size is
y after
erus 18
e to it.
+ than
mount
tis, the
1.
itis and
she cer-
GYNECOLOGY. 163
vix, to endometritis, obstruction of the Fallopian tubes or
malposition of the ovaries.
(h). Abortion is apt to take place if pregnancy occurs.
Diagnosis. The cervix is low, the os directed downwards
and the fundus is absent from the anterior fornix, but is felt in
the posterior fornix or by the rectum, and the angle between
the fundus and cervix can be felt behind. The sound has to be
bent and passes backwards.
-It must be distinguished from pelvic deposits in Douglas’
pouch and myoma of the posterior wall of the uterus,
Treatment. (a). Replacement. sem IRS
(a). By bimanual.
(8).' By the sound.
(y). By genn-pectoral posture combined with traction on the
uterus, with vulsellum and pressure on the fundus, with the
finger in the rectum. Before any of these manipulations the
hot vaginal douche and glycerine tampons should be used to
soften the parts and stretch any adhesions that may exist.
(6). Retention by Thomas’ modified Hodge, or Albert Smith
pessary.
5. Prolapsus or Procidentia Uteri. Owing to the
amount of loose tissue surrounding the bladder and rectum, we
get a weak point in the pelvic floor at which it separates, and
the uterus becomes displaced under increased abdominal pres -
sure. The pelvic floor is made up of two segments, the pubic
and the sacral. The pubic segment is made up of loose tissue
including the bladder, urethra, anterior vaginal wall and bladder
peritoneum loosely attached to the symphysis pubis. The
sacral segment is attached to the sacrum and coccyx, and con-
sists of rectum, perineum, and strong tendinous and muscular
tissue firmly dovetailed into the sacrum and coccyx. During
164 GYNACOLOGY,
labor the former is drawn up and the latter pushed down, act-
ing like folding doors, as the womb comes down between.
When: prolapse occurs you have. first the appearance of the
anterior vaginal wall at the orifice, spoken of as “ cystocele,”
then the uterus appears, then the posterior vaginal wall known
as “rectocele.” The uterus becomes more and more retroverted
as it comes down.
Symptoms. The patient complains of dragging and bearing
down, and afterwards of discomfort caused by the protrusion
and excoriation of the womb. There is usually dysuria.
Pathology. There ure three factors :—
(a). Deficient sacral support. Thus as a result of labor the
sacral support has become straightened out or deficient at its
lower margin—the perinenm. It does not always follow in
every case of ruptured perineum, but in those cases where as
some hold the perineal body has been torn through, or as others
hold where there has been a tearing of the perineal muscles,
especially the levator ani, that prolapsus occurs.
(b). Deficient tone of the pubic segment of the pelvic floor.
(c). Intra-abdominal pressure. This is the most important
factor. The uterus itself has very little to do with prolapse
except by its weight, when it is hypertrophied or has a fibroid
dragging upon it, and it may be likened to a hernia, the sac
being the peritoneum, and the canal being the space between
the bladder and the rectum.
Diagnosis. From inversion and polypus. ‘
Treatment. ‘a). Palliative—the use of pessaries. In slight
cases Hodge’s, or the elastic ring pessary. Then rest, with
alum injections and a good abdominal belt.
n, act-
of the
ocele,”
known
verted
earing
rusion
or the
at its
low in
here as
s others
nuscles,
floor.
portant
rolapse
fibroid
the sac
etween
is
| slight
, with
GYNACOLOGY, 165
(b). Radical. (a). Repair of a ruptured perineum.
(8). Making a raw surface on anterior wall of vagina
or on beth sides, and stitching them together we lessen the
calibre of the vagina and so keep up the uterus. ““ By Cnhols
Pessaries. Perhaps there is no instrument so much wrongly
used as the pessary, though much benefit may be derived from it
judiciously applied. Some physicians think that. if any dis-
placement be found and often when symptoms are merely
obscure, a pessary must be inserted. While therefore the
pessary may do a great deal of harm when thus used, it is
largely this ignorance in regard to its proper application which
has brought it into so much discredit. First then be sure of
the diagnosis and the amount and nature of the displacement ;
always replace the uterus before inserting one; be sure of the
absence of periuterine inflammation ; if adhesions exist loosen
them by previous applications of glycerine tampons ; select a
special pessary for each particular case just as you would fit a
splint for a fracture ; if painful remove it and see for yourself
at once or within a few hours that it suits the patient; she
should be informed of its introduction, how long it is likely to
be required, if painful to remove it and to use a daily vaginal
douche for the sake of cleanliness. Pessaries should rarely, if
ever, be used in young unmarried women.
6. Inversion. The uterus is turned inside out so as to
form.a polypoid projection into the vagina, its peritoneal sur-
face is converted into a cup-shaped hollow, its mucous lining
being everted and exposed in the vagina.
Pathology. A portion of the muscular wall of the uterus,
usually the placental site, having lost its tone, becomes dupressed
towards the uterine cavity ; muscular contractions of the non-
depressed portion of the uterus, combined with intra-abdominal
pressure or traction from below, as by pulling on the placenta,
at \«
SS SSS
SS
<=
—S
166 GYNZCOLOGY.
or tension on the pedicle of a polypus, carry the depressed por-
tion further into the uterine cavity, until the fundus reaches the
os and by a continuation of the same process dilates the cervi-
cal canal and passes into the vagina.
It is caused most frequently by labor, occurring however only
as 1 to 140,000 cases, and is much rarer now since the adop-
tion of Crede’s method of conducting the 3rd stage; the other
less frequent cause being the traction of a pediculated fibroma
attached to the fundus.
Symptoms. Hemorrhage, bearing down pains, anemia and
weakness.
Diagnosis. A digital examination reveals a rounded or
flattened soft tumor, which bleeds easily, is free on all sides
except at its upper extremity, around which is felt the cervix,
the lips and fornices being recognized, or the cervix is thinned
out to a ring and the fornices obliterated. With one finger in
front and the other behind the tumor, liftit up towards the
abdominal wall upon which is pressing the external hand; the
latter feels in place of the fundus a truncated body with a
depression in the centre. By drawing down the inverted uterus,
the finger in the rectum feels the depression in the fundus, and
a sound in the bladder can be felt by the finger in the rectum.
It is to be distinguished from a polypus and prolapse.
Prognosis. The greater proportion of unrelieved cases end
fatally from anemia, hemorrhage, septiceemia or peritonitis.
Treatmen'. (a). Reposition. For a few days before the
operation the patient should be prepared by perfect rest in bed,
vaginal injections of hot water, a liberal diet and tonics. Place
the patient in the lithotomy position and etherize. Pass the
finger as far up as possibie in the vagina and grasp the uterus,
and press it upwards against the left hand on theabdomen. To
ger in
ds the
d; the
with a
uterus,
1s, and
ectum.
38 end
tis.
e the
n bed,
Place
ss the
iterus,
a Be
. GYNECOLOGY. 167
rest the hand a cup is set on a curved iron rod with a spring,
known as Aveling’s repositor, which is pressed against the chest
and continuous pressure thus kept up for from 4 to 2 hours,
(b). Amputation. This is only justifiable after all other
means have failed. The tumor is drawn down, an elastic liga-
ture is tied around it as high as possible to control hemorrhage,
the uterus is cut off, and any bleeding vessels tied or seared
with the cautery.
VI. NEW-FORMATIONS.
1. Fibro-Myoma. The so called “fibroids” consist of
connective tissue and involuntary muscular fibre. They are
most frequently found in the posterior wall of the body of the
uterus. They cut like cartilage and are surrounded by loose
fibrous tissue constituting a capsule, the looseness of which is
important in their removal by eneucleation.
They are all interstitial at first, but may grow outwards and
become subperitoneal, these often developing a pedicle ; or they
may grow inwards and lie under the mucous membrane, project-
ing into the cavity of the uterus, and are called submucous.
The preseace of these growths leads to hypertrophy of the
uterus, to displacement, prolapse or inversion. They them-
selves may undergo softening from cedema, fatty or myxomatous
degeneration ; induration from fatty degeneration of the
muscular tissue and contracting of the fibrous ; calcification ;
or suppuration, which may lead to fatal peritonitis.
Symptoms. They often exist without causing any symptoms
and may only be recognised after death, but they usually give
rise to some disorder, especially the submucous variety :-—
1. Hemorrhage. This is especially characteristic of the sub-
mucous variety, and it occurs from the hypertrophied mucous
membrane and not from the tumor.
168 GYN ACOLOGY.
2. Dysmenorrhaa. Congestion of the mucous membrane
especially at the seat of the tumor causes obstruction to the
menstrual flow and produces uterine contractions.
3. Dragging and bearing down pain, owing to the increased
weight of the uterus.
4. Reflex phenomena, such as dvsuria or even eneuresis, consti-
pation or mucous diarrhcea, piles and varicose. veins,
5. Sterility or abortion, or obstruction to labor.
Diagnosis. 1. Of small tumors. If a submucous fibroid is
suspected as the cause of uterine hemorrhage, dilate the os with
steel dilator and explore with the finger. If interstitial, it may
often be detected by vaginal, rectal or bimanual examination.
2. Of large tumors. These are of even more importance,
requiring to be distinguished from advanced pregnancy, ovarian
tumors, extra-uterine gestation, hematocele and inflammatory
deposits. Proceed then in a systematic manner by :—
a. Palpation. They have a well-defined outline, hard and
firm, and there is absence of fluctuation.
6. Percussion indicates dulness.
c. Auscultation gives the uterine souffle.
d. Vaginal digital examination shows cervix high up and
uterus variously displaced according to situation of the growth.
e. Bimanual shows large mass continuous with cervix when
interstitial, and if subserous the tumor is felt distinct from,
but attached to, the uterus.
J. The sownd shows increased size of uterine cavity, and if
submucous fibroid the cavity is tortuous.
Ovarian tumors are soft and elastic and give no uterine
soufile.
then
D
twice
seve
»)
Dilat
a bis
shou
sloug
hurri
b.
the e
fully
simp
are I
SY
brane
o the
‘eased
onsti-
‘oid is
$s with
t may
ion.
tance,
arian
natory
‘d and
p and
‘owth.
when
from,
nd if
terine
GYNACOLOGY. 169
Treatment. 1. Mepicat, Ergot, by causing contraction of
involuntary muscular fibre diminishes the amount of blood
supply and so checks their nutrition, and also favors their
pedunculation and expulsion.
R—Ergotine,
Chloral Hydratis,
Dose, gtta. xii. (= gr. 3) injected deeply into the gluteal region
twice a week for the first few weeks, afterwards once a week for
several months,
2. Suraicat. a. Removal through vagina, eneucleation.
Dilate the os, incise the mucous membrane over the tumor with
a bistoury or thermo-cautery, and the separation of the tumor
should then be left to uterine efforts aided by ergot, unless
sloughing occur, when the process of eneucleation must be
hurried by the curette, using antiseptic douches.
b. Removal by Laparotomy. The pedicle is best treated by
the extra-peritoneal method. Dr. Apostoli has lately success-
fully treated by electrolosis.
2. Fibro-Cystic Tumor. The majority of these are
simply fibroids which have become softened, for the cavities
are not cysts but loculic ntaining serum.
Symptoms. Usually begin just as subperitoneal fibroids, and
then acquire fluctuation.
Diagnosis. They are apt to be mistaken for ovarian tumors,
but the cavity of uterus is larger, and on moving the tumor
externally by manipulation the sound moves also. Then draw
off some of the fluid with hypodermic syringe ; it coagulates like
serum, whereas that of an ovarian tumor does not.
<
‘s .3
eo
> 2
wT
Vy x
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NS
G
a
16
4
128
IMAGE EVALUATION
TEST TARGET (MT-3)
, Ye
BA GF a, JE XP <
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.
RR RR NE re
170 GYNAC LOGY.
Treatment.— Laparotomy, but be prepared for hysterectomy if
necessary.
3. Uterine Polypi. Are pediculated tumors attached to
the mucous membrane of the uterus.
(a) Pediculated Submucous fibroid.
(b) Mucous Polypi are usually developed from the mucous
membrane of the cervix. They are soft, about the size of an
almond, and usually multiple.
(c) Pediculated cystic follicle: are merely retention cysts.
(d) Placental polypus is produced as the result of incomplete
detachment of the placenta. It grows by coagulation of fibrin
upon its surface until it becomes of the size of an egg.
Symptoms. Hemorrhage.—This may be at first a menorr-
hagia, and it may become very serious.
Leucorrhea is a symptom due to the accompanying endo-
metritis.
Dysmenorrhea is a symptom due to uterine contraction.
Diagnosis. When the os is dilated you can easily detect the
protruding polypus with the finger; when the os is undilated
and a polypus is suspected, dilate and examine.
Treatment. If the tumor is small, dilate and remove with a
curette ; if larger, seize it with forceps and twist off the pedicle ;
using caustic or not.
4. Carcinoma or Cancer. Cancer or Cervix. May be
scirrhus or epithelioma. It may begin inside the cervix or on
its vaginal aspect. It spreads by forming nodules and ulcerating,
and invading the surrounding organs.
ED art eR ee Me NO Te eT TS ae ee
C
bilit
T
cata
S
ustis
par
shar
T
toge
sym
L
grov
The
lum
but.
T
eros:
ulce
P
from
T
and
injec
SI
nigh’
ched to
mucous
ze Of an
sts.
omplete
of fibrin
menorr-
g endo-
on.
tect the
dilated
e with a
pedicle ;
May be
ix or on
erating,
GYNECOLOGY. 171
Causes. The predisposing causes are heredity, age or de-
bility.
The exciting causes are erosion of the os and protracted
catarrh, lacerated cervix, ete.
Symptoms. The local symptoms ave hemorrhage, which is
usually the first symptom noticed ; an offensive watery discharge ;
pain, which is not always present, but if it is, the pain is severe,
sharp, lancinating, persistent.
The general symptoms are loss of flesh and debility, which
together with anemia gives rise to a cachectic appearance ; reflex
symptoms as painful micturition, defecation and pruricus vulve.
Diagnosis. The patient usually does not come until the
growth has begun to ulcerate, and then the diagnosis is easy.
The vaginal digital feels the everted mushroom os. The specu-
lum may be used, but is seldom necessary unless once to verify).
but is painful, and should not be reinserted.
The differential diagnosis is from hypertrophy of cervix with
erosion ; laceration of cervix with ectropion ; and syphilitic
ulceration.
Proynosis. Is grave and usually fatal, death occuring usually
from exhaustion or septicemia,
Treatment. Palliative. Check the hemorrhage by styptics
and ergot ; the offensive discharge by astringent and antiseptic
injections, as :
BR
Acid Carbolic . . . . loz
Hydrarg. Bichlor. . . 1! dr.
Morphie . . .. . . 8 grs.
Glycerine ad . . . « 80%
Sic. Tablespoonful to two quarts of hot water, and inject
night and morning,
| } 172 | GYNECOLOGY.
| The pain is to be assuaged by morphia, and the general symp- r
toms are to be attended to. niz
| Chian turpentine is said to have a marked effect upon the atu
| | disease. gen
| Radical. Caustics, scraping out the diseased tissue, amputa- .
' tion of the cervix, and lastly, hysterectomy has lately been suc- —
| cessfully performed in some cases. init
Cancer of body of Uterus is rarer than that of cervix, occurs ies
! . usually later in life and is more common in nullipare. nil
| Symptoms are the same, the cervix usually at first normal, soft
ee but uterusitself enlarged and hard. Dilate os under an anesthetic, wat
| curette, and examine the scrapings for cancer cells. '
| | VII. LACERATION OF THE CERVIX. stre
"| | The recognition and surgical treatment of this condition is ae
A, one of the many operative advances of the last 20 years, and is ~“
ne due to the genius of Dr. Emmet, of New York. eae
it
| Dr. Thomas says, “ the diagnosis and treatment of lacerated diti
a cervix is a pathological contribution which, even if this eminent mist
io ) author had done nothing else to lay his profession under obliga- [J and
ih | tion, would indelibly write his name upon the records of Gyne- the
4 cology. No one contribution to this department which has posi
| been made in the period mentioned has exerted a more marked the
te influence upon uterine pathology than this is now doing, and ff 9
p will do in the future. None will have more influence in abolish- Sie
+ ing useless and hurtful therapeutical resources.”
i Although laceration of the cervix was described by Dr. *
i Bennett forty years ago, its importance as a pathological factor JR =
ia was only recognized by Emmet in 1862, when he at once set tion,
J about a means of cure. He first published an account of his The
operation in 1869, but it was not until 1874 that general atten- eith
tion was drawn to the subject. the |
1 symp-
pon the
um puta-
een suc
, occurs
normal,
ssthetic,
lition is
, and is
acerated
eminent
y obliga-
f Gyne-
rich has
marked
ing, and
| abolish-
by Dr.
once set
mt of his
al atten-
al factor fF
GYNECOLOGY. LES
The existence of a laceration may sometimes be early recog-
nized by the presence, after confinement, of an elevated temper-
ature, indications of septicemia, the absence of milk, and a
general impression that the patient is not doing well. These
symptoms are due to cellulitis, which sometimes occurs with a
laceration of the cervix, without which it would otherwise have
healed, but which causes local obstruction of the circulation,
and so arrests involution and the repair of theinjury. It would
be well, therefore, when such a condition occurs after labor, to
make an examination, not immediately when the parts are so
soft that the tear could not be felt, but six or eight weeks after-
wards, and then by appropriate means prevent a life of suffering.
Now, while on the one hand I believe some have laid more
stress upon this condition than they should, and have even
operated when it was not necessary, Emmet going so far as to
say that “at least one-half of the ailments among those who
have borne children are to. be attributed to lacerations of the
cervix”; on the other hand there is little doubt that this con-
dition is often overlooked by the general practitioner, or it is
mistaken for erosion of the os (so called ulceration), or cancer,
and either improperly treated or neglected. A middle course is
the safest one, and the truth probably lies in the following pro-
positions :—1. A certain degree of laceration of the cervix is
the rule in all first labors.
2. A certain number of these are entirely recovered from, or
else they exist without producing any symptoms.
3. A certain proportion form important factors of disease.
It is this last class of cases that alone require Emmet’s opera-
tion, and in which relief of the symptoms may be expected.
The tendency then of laceration of the cervix is to heal unless
either septic poisoning takes place, or the tear extends beyond
the crown of the cervix into the connective tissue, the accom-
Se
"he
\
174 GYNECOLOGY.
panying cellulitis obstructs the circulation, interferes with invol-
ution, and thus prevents repair of the injury. It is most
commonly met with on the left side, probably because the vertex
usually occupies the right oblique diameter ; and the next in
frequency is the bilateral.
Symptoms. When a laceration of the cervix exists, there is
a tendency, especially on standing, for the uterine tissue to roll
out, while the obstructed circulation, the irritation of the vagina,
and the resulting sub-involution increase the laceration ;.and
as the vaginal outlet is usually patulous—owing perhaps to the
us of forceps, or traction, or the accompaniment of a ruptured
perineum—there is usually prolapse or retroversion. The
reticulated mucous membrane, containing numerous Nabothian
glands, undergoes cystic hyperplasia and granular degeneration,
resulting in a condition closely resembling erosion (so-called
ulceration), or even cancer.
Then we have inability to walk or stand comfortably, back-
ache, pains in the abdomen, irritability of the bladder, profuse
‘ menstruation, leucorrhcea, headache, insomnia and other ner-
vous derangements, and lastly sterility ; or if pregnancy should
occur, it usually results in abortion.
If neglected it may result in chronic parametritis, cancer, sub-
involution, sterility ; if pregnancy occurs, a tendency to abort ;
menstrual disorders, endometvitis, dispareunia, and displace-
ments. .
Diagnosis. Readily felt by finger, and then put the patient
in the Sims position and use Sims’ speculum and a tenaculum or
vulsellum, and by bringing the two lips in apposition you can
tell at once the amount of laceration. It is to be distinguished
from erosion, syphilitic ulceration and cancer.
Treatment. Trachelorrhaphy. The method which I have
employed for some time past is to mark out the intended
incision with a scalpel, remove the angle or cicatricial plug
(as it
trim
up w
tissue
on m
there
re-opt
I.—
Is
cellul.
The
that t
them.
the pe
and tl
found
accum
fF uterus
s This i:
® tiona
each sg
betwe
Car
absort
cervix
beneat
glands
are en
The
operat
h invol-
is most
e vertex
next in
there is
e to roll
vagina,
ym ;-and
3 to the
uptured
;' “Phe
bothian
eration,
so-called
y, back-
profuse
ler ner-
y should
er, sub-
D abort ;
lisplace-
patient
ulum or
you can
guished
I have
4 tended
al plug
GYN.ECOLOGY. 175
(as it has been called) with Skene’s Hawkbill Scissors, then
trim the edges with knife and long handled scissors, and stitch
up with chrcmic catgut. This has the power of resisting the
tissues for two weeks, and can be removed with the finger nail
on making an examination after that time, up to which period
there is no need of disturbing the patient, nor any danger of
re-opening the wound, as there is with either silk or silver wire
D.—DISEASES OF THE PELVIC CONNECTIVE TISSUE.
I—PARAMETRITIS, OR PELVIC CHLLULITIS.
Is an acute or chronic inflammation, usually septic, of the
cellular tissue of the pelvis.
The peritoneum is so closely applied to the body of the uterus
that there is no separating the layer of connective tissue between
them. In the same way there is little connective tissue between
the peritoneum and the posterior wall of the vagina, between it
g and the bladder or between it and the rectum. There is more
found between the uterus and the bladder, but the greatest
accumulation of connective tissue is found laterally at the
| uterus, the parametrium proper or Virchow’s parametric tissue.
; This is important from a diagnostic point of view, as inflamma-
* tion and exudation of the parametrium would be looked for at
each side of the uterus, although it may extend to that tissue
between the uterus and the bladder.
Causes. In parous women the ¢ at cause is septic matter
absorbed by the lymphatics from tne torn perine:im, vagina or
cervix. This passes along the lymphatics in the cellular tissue
beneath and in the brood ligaments, causing inflammation of the
glands and proliferation of the connective tissue in which they
are embedded.
The same may follow premature labor, abortion, gynecological
operations, and even a very prolonged and tedious labor.
| | | 176 GYN ZCOLOGY.
| t) Symptoms. It usually sets in with a rigor, then fever, and out
t | | pain over the lower part of abdomen, which is increased by Yo
by pressure and is more severe laterally. After the exudation occurs, dur
i. one leg is usually drawn up, and a fulness is felt usually at one exe
ihe side of the uterus which is itself pushed over to the opposite sho
| | side. The lameness and stiffness of the thigh often remain for -
# fh months. Ss
hl ; for
| ie Prognosis. The inflammation may be arrested and the effu- shor
j . sion absorbed, or it may go on to form an abscess which may
} | open into the bowel, or bladder, or pass below Poupart’s ligament, (é
ie or up towards the kidney, It usually takes months to ripen vag!
. i and recovery is tedious.
a Treatment. Same as that of perimetritis.
| Il—PHRIMETRITIS, OR PELVIC PERITONITIS. | Is
ai) some
| | Is an acute or chronic inflammation of the pelvic peritoneum, peri
1: and is not always of septic origin.
| Causes. Extension of pelvic cellulitis ; rupture of ovarian ai
| cysts, fibroids, tubercle or cancer; child-birth and abortion ; eee
thi gonorrhea spreading up the tubes ; cold during menstruation, Ke -
1 venereal excess, or instrumental manipulation.
i Symptoms. There may or may not be a rigo”; then fever 2.
1 sets in and severe pain in abdomen increased by palpation ; the offus
| patient lies on her back with legs drawn up; the vagina feels and.
f hot and tender, After exudation occurs, a flat hard unbulging Hi:
- condition of the fornices around the cervix is felt, and the symy
i | uterus becomes immovable, feeling as if plaster of paris had been the ]
a | poured into the pelvis and had set all round the uterus. The fF have
bulging is specially marked in Douglas’ pouch. B to oc
4 i Prognosis. It may resolve or suppurate, and is not usually <a
Fy e
fatal, unless it becomes general.
Treatment.—1. Prophylactic. Always scrupulously carry Ca
yer, and
used by
occurs,
y at one
opposite
nain for
the effu-
ich may
gament,
to ripen
ITIS.
toneum,
ovarian
maka ;
rruation,
en fever
ion ; the
ina feels
nbulging
and the
had been
s. The
usually
sly carry
GYNECOLOGY. 177
out antisepsis in labor, abortion or gynecological operations.
Young women should be warned to avoid all undue fatigue
during their menstrual periods, as well as late hours, violent
exercise and alternate exposure to heat and cold. Gonorrhcea
should be thoroughly treated, especially during pregnancy.
2. Curative.—(«) General. Morphia to ease pain ; aconite
for fever, and quinine to combat the septic condition. The diet
should consist of iced milk, beef tea, soup, and champagne.
(b) Local. Leeches over iliac region, hot fomentations, hot
vaginal douche, and later on glyce sine tampons.
III PELVIC HAIMATOCELE.
Is an effusion of blood, usually into the pelvic peritoneum,
sometimes beneath it ; hence there are two varieties, the intra-
peritoneal and the subperitoneal.
1. Intraperitoneal hematocele is the more serious, and if the
effusion is rapid, death may take place »efore it has time to
coagulate, or if it is slower, violent inflammatory action is sure to
be set up.
2. Thesubperitoneal ov encysted variety is when the blood is
effused into the cellular tissue surrounding the uterus, ovaries
and pelvic viscera.
Hematocele is n> more a disease than hemoptysis, but is a
symptom of some previously existing pathological condition of
the pelvic organs. It is only since 1850 that gynecologists
have really had their attention drawn to this condition, so liable
to occur owing to the abundant venous supply of the pelvic
organs, the congestion induced by menstruation, and the hemorr-
hage accompanying the monthly rupture of the Graafian follicle.
Causes. The predisposing cause is the period of ovarian
13
178 GYNECOLOGY.
activity, especially that of greatest sexual vigor, viz. : between
20 and 30, und at the menstrual period.
The exciting causes are sudden suppression of menstruation
from cold, mental shock, undue exertion, over fatigue, violent
straining at stool, external violence, premature exertion after
abortion, ete.
The source of the blood may be from the veins of the pelvic
peritoneum, connective tissue, uterus, or excessive hemorrhage
from rupture of Graafian follicle.
Symptoms. The sudden onset of anzemia, and signs of internal
hemorrhage, accompanied by pain, difficulty in urination and
defecation, a feeling of fulness and bearing down and the pres-
ence of a tumor behind the uterus. The uterus is pushed for-
ward, and when coagulation takes place the tumor can be
displaced by the finger through the posterior vaginal wall, often
with a creaking sound, and feels not unlike scybala in the
rectum,
The condition often simulates acute poisoning.
Diagnosis. It is to be differentiated from pelvic peritonitis,
pelvic cellulitis, fibroid in posterior wall of uterus, extrauterine
pregnancy and retroversion of uterus.
Prognosis. Tt may undergo absorption, an indurated mass
remaining for months and being finally absorbed, or it may
undergo suppuration, or death may occur very early from hemor-
hage or exhaustion. I terus often occurs from absorption of
heematin.
Treatment.—-1. Preventive. Obstructive dysmenorrhea
should never be neglected. Fatigue, dancing, exposure, etc.,
Should be avoided during the menstrual period. Cases of menor-
hagia and « sortion should also be watched.
2. Curative-—(a) Of the subperitoneal variety, the expect-
aspi
A
een
tion
lent
after
elvic
hage
ernal
| and
pres-
dl for-
in be
often
n the
ynitis,
terine
| mass
[| may
lemor-
ion of
rrhoea
, etc.,
nenor-
>xpect-
GYN ECOLOGY. 179
ant plan is the best : rest, ice bags, ergot. If collapse, use stimu-
lants; and if pain, give morphia. Firm bandaging is good. ‘If
suppuration occurs, open and drain antiseptically. Never incise
a recent heematocele.
(6) Of the intraperitoneal variety, early performance of laparo-
tomy and securing the vessels is best.
E.—Diskases or THE TUBES AND OVARIEs.
I. OF THE TUBSS.
Strictures of the fallopian tube may occur from perimetritis,
the tube being bound by binds of lymph, ov the fimbriated
extrem'ty matted together by lymph so as to effectually close
the tube. This results in sterility or hematocele, and if only
partial may give rise to extra-uterine gestation.
Salpingitis, or inflammation of the tubes, is usually the result
of the extension of endom+tritis and is very frequently caused
by gonorrhea. As a consequence of this, serum may accumulate
and distend the tube, when it is called Hydrops tube ; ov if
Suppuration results, Pyosa/pinx ; or if it fills with blood,
Hematosalpine.
Diagnosis. This is difficult and often impossible, but hydro-
salpinx may sometimes be distinguished from an ovarian cyst
by the swelling being more tortuous and elongated, more
anterior and often felt behind Poupart’s lgament, and often
symmetrical ; or if one tube is affected it usually pushes the
uterus to the other side. Draw off some of the fluid with an
aspirating needle and examine it.
Treatment. Laparotomy.
II. OF THE OVARIES.
1. Prolapse of the ovary into Douglas’ pouch sometimes
occurs, Here it may become inflamed and fixed, giving rise
ee
180 GYNACOLOGY.
to a sickening feeling in defecation or walking, and to dispar-
eunia, and is a very frequent cause of ovarian dysmenorrhea.
It can readily be felt on examination, and is usually the left,
to one side of the uterus and low down. It is very sensitive to
touch, giving rise to the same sickening sensation as pressure
on an inflamed testicle. It can readily be distinguished from
retroflexion by a careful bimanual and rectal examination, and
by the uterine sound.
Treatment. The genu-pectoral position and use of a padded
Hodge pessary to distend the posterior cul-de-sac. Hot vaginal
douche, pessaries of morphia, avoidance of prolonged exertion,
regulation of the bowels and the use of potass. brom.
2. Odphoritis. May be acute or chronic, the latter being
more common.
Causes. Gonorrhcea; childbirth and abortion ; obstructed
menstruation ; acute febrile diseases, such as cholera, the
exanthemata, septicemia, phosphorus and arsenic poisoning and
perimetritis,
Symptoms. Pain in the iliac fossa radiating to the back and
increased by pressure; the ovary can be felt enlarged and
tender.
It may result in resolution, adhesion or suppuration and
abscess.
Treatment. Hot vaginal douche, hot fomentations and mor-
phia suppositories. In the chronic variety, glycerine tampons,
and. potass. iodid. Should it resist all treatment, an operation
has been devised for its cure.
Oéphorectomy, or removal of the tubes and ovaries, is indicated
In several conditions and known by the name of the operator.
Thus Battey tirst did it for the cure of those cases where hy-
stero-epilepsy, convulsions and insanity depend on ovarian
disease ; Hegar did it for uncontrollable bleeding from fibroids ;
tl
tc
par-
hoa.
‘left,
e to
sure
from
and
dded
inal
‘tion,
and
and
mor-
pons,
ation
rated
ator.
» hy-
rian
vids ;
GYNECOLOGY. IS]
and Z'ait for intolerable dysmenorrhea due to pyosalpinx,
hematosalpinx, prolapsed or otherwise diseased ovarie ..
Operation. May be vaginal or abdominal, the latter being
preferable in most cases, Every antiseptic precaution must be
thoroughly carvied out. An incision is made 4 inches long
from the mons veueris upwards. All bleeding to be carefully
stopped as the tissues are each cut to the peritoneum, which is
then incised. Then pass the index finger down to the fundus
and carry it along the fallopian tube to the ovary, which is
5
lifted out, caught with snap forceps, ligated, and the silk cut
short. The peritoneal toilet is made carefully, and the abdom
inal incision is closed by one continuous cat gut suture, taking
up the edges of peritoneum first, then the sheath of recti, and
then the skin. An antiseptic dressing and binder completes the
_ operation.
3. Ovarian Tumors. They may arise from a Graatian
follicle that has not ruptured but become distended, and when
small they have a similar structure, viz: a fibrous coat derived
from the stroma of the ovary and an inner coat lined with
epithelium corresponding to the tunica propria of the follicle,
and enclosing a clear fluid. They may arise from a corpus
luteum ; from colloid degeneration of the ovarian stroma ; from
pathological development of enclosed germinal epithelium (the
so-called Pfluger’s ducts). Dermoid cysts are skin-like in
structure and contain bones, teeth, hair, ete., and are formed
by a displacement of the external layer of the blastoderm, a
portion of which becomes included in the part of the middle
layer from which the ovary is formed, Lastly they arise from
malignant development of the connective tissue of the ovary.
The cyst of an ovarian tumor may be single or multiple, and
the pedicle is usually made up of ovarian tigament, fallopian tube
and broad ligament with vessels, all being covered with peri-
toneum. The fluid contained in the cysts varies in consistence
gps
iain ernment caiaintiamaseaacaataia
182 GYNACOLOGY.
and color from a clear, thin, watery fluid to a viscid or semi-
solid gelatinous mass. It does not give a flocculent precipitate
as ascitic fluid does. It may also contain oil globules, choles-
terine crystals, blood and large granular cells, and a corpuscle
has been described as characteristic of ovarian fluids, a round
delicate, transparent cell containing a number of granules, but
no nucleus, and varying in size from the soso to zoo of an
inch,
Ovarian tumors occur most frequently between 20 and 40
years of age, most commenly in those who are sterile or
unmarried, Anything which intensifies ovarian congestion is
apt to give rise to them ; thus women who have suffered long
from congestive or obstructive dysmenorrhea are apt to have
ovarian growths,
Symptoms. (a). When small (pelvic). Pain is often felt in
the region of the ovary ; there is ovarian dysmenorr! cea, irrita-
bility of the bladder and a desire to micturate, discomfort in
the bowels often amounting to tenesmus, and usually displace-
ment of the uterus.
(b). When large (abdominal), Ags the tumor enlarges it fills
the abdominal cavity, and the symptoms now are mainly those
of pressure, such as dyspnoea, aching in the loins, cedema of
the legs and varicose veins.
In these cases there is generally a history of gradual enlarge-
ment of the abdomen commencing usually on one side ; not
tender on pressure; easily displaced ; causing little or no
inconvenience until it becomes bulky and reaches above the
umbilicus ; the general health, at first good, becomes gradually
imj aired ; the abdominal veins enlarge; the facial expression
becomes altered, cedema of legs sets in, and then a physical
examination reveals a tense elastic tumor, dull on percussioh,
fluctuating and distinct from the uterus,
semi-
vitate
holes-
uscle
‘ound
, but
of an
d 40
le or
on is
long
have
elt in
rrita-
ort in
place-
t fills
those
na of
large-
; not
r no
> the
ually
ssion
sical
sioh,
GYN ECOLOGY. 183
Diagnosis. It is seldom that you may be called upon before
the cyst has become abdominal, but if small it can be made
out by the bimanual and is to be distinguished from parame-
tritis, perimetritis and fibroid of the uterus.
It is often exceedingly difficult and the best surgeons have
made glaring mistakes, and very often an exploratory incision
will alone reveal the true nature of the case. It is well then
in every case to examine thoroughly and _ systematically,
endeavoring to make a reliable and trustworthy rather than a
brilliant and showy diagnosis, often arrived at too hastily and
regret‘ed at leisure. First get a history of the case, and then
after evacuating the bowels and bladder, examine by inspection,
palpation, percussion, auscultation, the bimanuai and rectal, and
by the use of the sound, and draw off some of the fluid with a
hypodermic syringe to examine it. It is to be differentiated from
typanites, ascites, hydatids, pregnancy, fibroids, and fibro-
cystic.
Treatment. (a). Tapping should only be resorted to as a
palliative, if there is great distension, but is contra-indicated if
an operation is possible.
(b). Ovariotomy. This may be done at any time, but is
somewhat easier when the tumor has attained the size of 6th
month of pregnancy as it has then displaced the intestines and
stretched and thinned the abdominal wall. A time ten days
after the menses should be chosen. ‘be operation is similar to
that of Odphorectomy until you come to the cyst, when the
patient is turned or her right side, the fluid evacuated with a
large trocar until the cyst walls become flabby, when the
opening may be enlarged with a scalpel to allow the fluid to
escape more rapidly. The cyst walls are then freed carefully
from any adhesions, which are first made out by passing a sound
between cyst wall and peritoneal lining of abdominal cavit~,
and the cyst is drawn out ; the pedicle is secured in two or more
184 GYN ECOLOGY.
sections with a strong silk ligature which is cut short and
dropped into the pelvic cavity. The remainder of the operatior.
is similar to that already described for removal of the ovaries.
In some cases it is necessary to use a drainage tube,
F.—DIsEASES OF THE BLADDER.
I—MALFORMATIONS.
The bladder is formed from the stem of the allantois, and the
deformities gnet with are due to some arrest in development
giving rise to atresia, fissures, diverticuli, patent urachus, and
ectopia. !
II.—CYSTITIS.
Inflammation of the bladder is frequent in the female, often
resulting from the proximity of neighboring inflammations, such
as parametritis, perimetritis, and metritis. The shortness of
the urethra permits a vaginitis to readily extend upwards.
Causes.—Gonorrhcea, exposure to cold, prolonged labor, intro-
duction ef septic matter by catheter or bougie, and prolonged
retention of urine.
Symptoms.—Pain and tenesmus of the bladder ; -burning pain
on micturition, and the urine is often high-colored and bloody, of
an acid reaction in the acute, and alkaline in the chronic variety.
Treatment.—In the acute form, alkaline mixtures with bella-
donna; morphia hypodermically, and locally hot fomentations,
but never use turpentine. In the chronic variety, nitric acid,
hyoscyxmus and buchu, or ammonium benzoate, and in bad cases
irrigation of the bladder with warm bichloride solution (1-20,000)
is often useful. The diet should be principally milk and lime
water, and linseed tea.
The reason why these cases are often so persistent may be
explained by reference to the process of urination. The urine
trick]
by m
an en
by th
diste1
expel
contr
tion |
to th
tabili
Ste
they :
dilate
lime,
Sy
close
the s
in th
Tr
by di
ing 1
large
anter
Fo
tastes
extra
worn
t and
ration
varies,
id the
pment
s, and
often
;, such
ess of
Ss
intro-
longed
ig pain
, dy, of
ariety.
bella-
tions,
acid,
i cases
0,000)
id lime
hay be
urine
GYN ECOLOGY. 185
trickling from the ureters partly by blood pressure, and partly
by muscular contraction of the ureters, passes into the bladder,
an empty flaccid sac. The urethral muscles are kept contracted
by the activity of the motor centre, and as the biadder gradually
distends, the former is reflexly inhibited, and the urine is
expelled by muscular contraction of the bladder, aided by the
contraction of abdominal muscles and diaphragm. This condi-
tion of the bladder of contraction and flaccidity may be likened
to the systole and diastole of the heart, and explains the intrac-
tability of inflammatory conditions of the bladder.
III.—CALCULI AND FOREIGN BODIBS.
Stone is less frequent in the female than in the male, since
they are apt to pass at an early stage owing to the shortness and
dilatability of the urethra. The uric acid, phosphatic, oxalate of
lime, and cystic calculi are met with.
Symptoms.—Severe pain on micturition, especially at the
close ; alterations in the character of the urine, and hematuria ;
the stone can be felt by the bimanual, and verified by the sound
in the bladder.
Treatment.—If less than an inch in size, it may be removed
by dilating the urethra with the finger or speculum and extract-
ing with forceps; if larger crush and remove it ; and if very
large arfd hard it may be removed by an incision through the
anterior wall of the vagina.
Foreign bodies introduced wilfuiiy by patients of depraved
tastes may be removel by polypus forceps, or if large may be
extracted by vaginal incision.
IV—FUNCTIONAL DISEASHS.
1. Irritability.—May be due to acidity, neivousness or
worms.
Treatment. Remove the cause.
SS eee ee
186 GYN ACOLOGY.
2. Incontinence.—7reatment.—Remove any source of
irritation, and give iroi: and belladonna,
3. Retention.—May be due to:
(a). Hysteria.
(b). Heflew action, such as piles, gonorrhea, tears of per-
ineum, etc
(c). Mechanical obstruction, such as the presence of fibroids,
ovarian tumors, or retroversiO.u.
4. Dysuria, or painful and difficult micturition, is often due
to digestive derangements where the urine becomes very acid ;
or if the patient perspires too freely ; or to the presence of ante-
flexion ; to paralysis of the bladder from prolonged retention ; or
to exhaustion of nerve power.
V. NEW GROWTHS.
The bladder may be examined by the catheter and sound ; by
finger; and by the speculum. The most common growth
which occurs in the bladder is a villous tumor, which is usually
situated in the trigone and lower part of He bladder. It is
very vascular and bleeds readily.
Symptoms.—A re similar to those of stone, but the hemorrhage
is often severe, giving rise to anemia, and the sound ‘finds the
absence of a calculus,
Treatment.—Dilate the urethra, scrape out the growth witha
spoon, and wash out with a disinfectant, giving opium for the
pain.
VI. DISHASES OF THE URETHRA,
It is of great importance to make a correct diagnosis of these
diseases, and not to mistake cause for effect. Thus a fissure 0
the anus, inflammation about the utero-sacral ligaments, or pro-
lapse
ease
exam
I,
of sil
ally.
2.
I cathe
applic
butte
3.
poutil
can b
close
healec
4, (
sisting
being
much
Tre
Em
affecti
Altl
tems a
depenc
formec
partne
tion.
ously |
source of
‘3 of per:
f fibroids,
often due
very acid;
xe of ante-
sntion ; or
ound ; by
n growth
is usually
ler. It is
smorrhage
‘finds the
wth witha
im for the§
Le
is of these
. fissure 0
its, or pro
GYNECOLOGY. 187
lapse of the uterus may give rise to symptoms resembling dis-
ease of the urethra, and it is only by a careful endoscopic
examination that these conditions are to be correctly found out.
l. Urethritis is most commonly caused by gonorrhea, Nitrate
of silver solution should be applied locally and copaiba intern-
ally.
2. Fissure is apt to occur after the frequent use of the
catheter. It should be carefully sought for and nitrate of silver
applied, and afterwards bougies of iodoform, tannin and cacao
butter,
3. Prolapse of Urethral Mucous Membrane.
pouting completely surrounding the urethra, and the catheter
can be passed through the centre of it. It should be incised
close to urethra, and a catheter left in for a few days until
It appears as a
healed.
4, Caruncele is a small vascular tumor like a raspberry, con-
sisting of dilated capillaries in connective tissue, the whole
being covered with squamous epithelium. It often gives rise to
much pain and distress, causing reflex bladder symptoms.
Treatment.—Ablation and the thermo-cautery.
Emmet’s button-hole operation is useful in some of these
affections.
G.—NEUROSES.
Although the cerebro-spinal and sympathetic nervous sys-
tems are independent, they are yet in a certain way mutually
dependent upon one another. So long as functional life is per-
formed regularly the ganglionic system is, as it were, a silent
partner in the nervous arc, yet a busy one in maintaining nutri-
tion. Like the wheels of a watch they work together harmoni-
ously as long as each performs its proper function, and is
188 GYNACOLOGY.
undisturbed by extraneous agencies, and it is only when some
disorder occurs that the sympathetic system asserts its potency §
for evil by transmitting the morbid impression through the
spinal nerves to the brain. So in women, the brain participates
more or less in every disturbance of the ovario-uterine circle,
Still more so is this the case when the brain has been rendered
morbidly sensitive by tarlty education or overstraining, by
defective moral balance or some previous shock, the whole force
of any uterine disturbance is thrown directly on the cerebro.
spinal system. We have then headache, wakefulness, change in
disposition, irritable temper, and every grade of hysteria, up tof
actual insanity. Let us then consider some of these nervous
aberrations.
I—HYSTERIA.
The term hysteria is somewhat misleading as it has of late
years been shown to exist in men as well as women, but when
so found it is to be observed that such persons are either men-
tally and morally of feminine constitution, mentally over-
worked, exposed to emotional disturbance, or reduced in physi-
cal power. Hysteria manifests itself in various ways besices
convulsions, such as derangements of sensibility, and alterations
of motion.
Symptoms—1. Alterations in Mental Condition. These
cases are characterized by inability or rather indisposition to
exert the will, and the existence of illusions, hallucinations or
delusions. At one time she cries, then laughs, or both at the
same time without any sufficient cause.
2. Alterations in Sensibility.—(a). Hypercsthesia, o
excessive cutaneous sensibility, when of a hysterical origin, is
characterized by never being permanently fixed in one place;
is excessively acute, and is unaccompanied by serious disturb:
ance of the nerve centres.
2)
In th
so th:
‘ glo’ tis
CAUSE
test.
Hae
such ¢
bowel
Car
ation,
is mos
in the
apt to
educat
study
of the
T re
these,
cian h
Bupon a
charae
and re
her ca:
m assista
lesire
B cious,
thesia
electri
strychi
ate of
monob
shen some
S$ potency §
‘ough the
urticipates
ine circle,
. rendered
‘ining, by
vhole force
ie cerebro-
change in
aria, up tof
e nervous
as of late
but when
ither men-
ally over:
1 in physi-§
im these, and there is no doubt the greater success which one physi-
ys besides
alterations
on. These
position to
mations or
oth at the
rsthesia, or
| origin, 18
me place;
as disturb:
GYNAZCOLOGV. 189
(L) Anesthesia, or loss of cutaneous sensibility, is frequent.
In these cases the reflex excitability of the larynx is abolished,
so that the finger can be passed down the throat to the epi-
p glo'tis, which can be rubbed or scraped with tie nail without
causing any irritation, and this may be used as a diagnostic
test.
3. Alterations in Motility.— Various forms of paralysis,
such as hemiplegia, aphonia, and derangements of the stomach,
bowels and kidneys are due to this cause,
Causes.—It is most frequent in females of a delicate organiz
ation, and where the emotional system is highly developed ; it
is most common between the ages of 16 and 25; more common
in the single than married ; and all those influences are most
apt to give rise to it which are connected with refinement and
education, such as music, the reading of novels and poetry, the
study of art, etc., which develop the emotional at the expense
of the physical and intellectual.
Treatment.—No cases will s” test your patience and tact as
clan has over another in the treatment of these cases depends
upon a bett»r knowledge of human nature and a greater force of
character. The first thing is to gain the patient’s confidence
and respect, make hex believe that you thoroughly understand
her case, that she is not suspected of shamming, that with her
B assistance the trouble will be removed, and the effect which you
desire will probably be produced. Sympathy is often injudi-
scious, but firmness is always necessary. If there is hyperes-
thesia the bromides are indicated ; if anzesthesia the faradic-
electric current by meaus of the brush is a specific; for paralysis,
strychnia, phosphorus and electrici' y ; for vomiting, the valerian-
ate of caffeine ; for spasins, chloroform inhalations followed by °
monobromide of camphor; and during these attacks copious
1 190 GYNACOLOGY.
ri enemata of hot water, in which is mixed 1 ounce of tincture ” § systen
; rh assafcetida often acts specifically. the ge
Say | anore:
+) IL—HYSTERO-EPILEPSY anil
. cise al
io Is one of the most frightful of the nervous affections. We & algo a:
Bi cannot yet say positively if it is a special disease or ». combina- § which
Hi tion of epilepsy and hysteria. housel
| ; x ‘ wey
| he Symptoms.—-The attack begins like epilepsy, she recovers fm “vel
I consciousness, and then begin contortions of the face, neck, It i
i trunk and extremities, tearing with the hands and teeth any- posed
i thing within reach, the hysterical element now predominating, fF from ¢
( the patient alternately weeping and laughing, gradually becomes & joey
Hh sensible again. Sometimes it seems to prevail epidemically. traine
Yh eer By poe ee which
| Treatment.—The bromides, and galvanization of the sympa-
thetic. but w
F B obtain
III.—NBURASTHENIA. tricity
ty age many
Nerve exhaustion, or nervous prostration, is applied by Erb
TARsn
and modern authorities to a class of grave and intractable ner- & 4 hi
vous disorders, familiar to those who see much of the diseases of
women, It represents a class of women who have been from
one doctor to another, subjected to all sorts of medication, tried
a. all kinds of pessaries, until they have become confirmed invalids,
i more or less bedridden. Sleepless, the victims of chloral or
morphia, worn out in body and mind; in short, miserable
wrecks, burdens to themselves and their families. There is no
doubt these cases have been the result of uterine mischief, but
they have now got beyond the point at which local treatment
H ‘can be of any service or ever effect a cure. The pain, backache,
i leucorrheea, difficulty in walking, and disordered menstruation
have ended in producing a state of general disturbance in which
Hs all the bodily functions have become implicated. The nervous
neture «”
ns. We
combina-
recovers
ce, neck,
eth any-
ninating,
becomes
ically.
e sympa- |
‘| by Erb
able ner-
iseases of
een from
ion, tried
invalids,
hloral or
iserable
ere is no
thief, but
reatment
ackache,
struation
in which
» nervous
GYN ACOLOGY. 19,
system is profoundly affected, the blood is impoverished, and
the general nutrition at its lowest ebb. There is emaciation,
anorexia, dyspepsia, probably made worse by morphia. Asa
result of all this, and partly from pain, she has aband ned exer-
cise and keeps in the hous? or even in bed. Moral aberrations
also arise, both emotional and hysterical, She craves sympathy
which she often obtains to her own hurt, until at last the whole
household become victimized by the morbid selfishness thus
developed.
It is in such cases as these that Dr. Weir Mitchell has pro-
posed a plan of cure consisting in the removal of the patient
from the unwholesome moral surroundings in which she has
been living, away from sympathetic friends to thecare of a
trained nurse; in the renewal of her vitality by excessive feeding,
which under ordinary circumstances could not be assimilated,
but which is rendered possible by passive muscular exercise
obtained through the systematic use of shampooing and elec-
tricity. The elements of this treatment, which has resulted in
many cases of marvellous cure, consist of seclusion and rest ;
mussage, electricity, the faradic current with slow interruptions ;
and forced feeding.
192 PEDIATRICS.
PEDIATRICS.
While the infant may be regarded physically as the abstract
of the man, possessing the same organs, the same processes of
waste and repair, of growth and decay, still there are some
important structural and functional differences between child-
hood and adult life which modify and alter the diseases to which
the young child is liable. Thus in childhood the tissues are
softer, more vascular, and more succulent ; the glandular,
lymphatic and capillary systems are extremely active; the
skin and mucous membranes are softer, more delicate and more
sensitive; the brain is large, vascular, and almost fluid in
consistency ; there is excessive nervous excitability due to want
of controlling power; and reflex sensibility is excessively
acute. Thus some slight functional derangement such as the
presence of indigestible food will cause fever, extreme agitation
or even convulsions, and the onset of any acute affection is
apt to be ushered in by a convulsion instead of the chill which
is often the first indication in the adult.
Again, the rapidity with which infants part with their heat,
and so become easily chilled, makes them more prone to
catarrhal affections which may rapidly prove fatal, and so the
cause of death may be overlooked on making a post mortem
examination.
Then the diathetic tendencies, such as syphilis, scrofula or
tuberculosis, are especially active in the young, and exert
a remarkable influence upon the growing body, shaping the
figure, moulding the features, and so altering the structure that
if insanitary surroundings interfere with the nutritive’ processes
the mischief may be widespread.
W
still
objet
culti
stud
exal
some
dish
that
ence,
ivfar
agita
mere
of fi
infor
exam
a mo
If
or dt
usual
this :
you s
of thi
this 1
affect
stater
ated,
whicl
exam
illnes
and s
and t
death
bstract
esses of
> some
. child-
» which
1es are
ndula”,
e; the
1d more
luid in
to want
assively
as the
yitation
‘tion is
| which
ir heat,
rone to
so the
mortem
fula or
t exert
ing the
ive that
rocesses
PEDIATRICS. 193
While diagnosis is often a difficult task in the adult, it is
still much more so in the infant where our only guide is an
objective examination. The best means to overcome the difli-
culties of such an examination is to form a plan or method to
study them. So great are these difficulties in the clinical
examination of children that unless you have been prepared by
some preliminary study you will find it a most uncertain and
disheartening task to unravel the history and nature of any case
that may come to you. The task is one which requires pati-
ence, good nature, and tact, for the helpless silence of the
ivfant, the incorrect answers of the older child, the fright,
agitation, or anger produced by your examination, or even
mere presence, render it difficult to detect the real aberration
of function. And lastly, che difficulty of obtaining reliable
information from the mother or nurse all concur to make your
examination 0. children, with a view io find the seat of disease,
a most difficult and perplexing one.
If possible, you should try to see the child first when asleep,
or during or immediately after the act of nursing, as it is then
usually more or less drowsy, and more easily managed. While
this is going on, or even before you have seen the child at all,
you should enquire of the mother or nurse all about the history
of the case. Most women are good observers, and especially is
this the case in a mother whose watchfulness is increased by
affection and anxiety. You should listen attentively to her
statements, and although they may be foolish, false, or exagger-
ated, she will often be able to detect variations from health
which might escape the most acute and observant medical
examiner. The history should bear upon the causes of the
illness, its precise moment and mode of attack, and its course
and symptoms up to the present time ; the health of its parents
and their previous diseases; or if they are dead, the cause of
death, The hygienic surroundings should be taken in; the
14 ,
194 PEDIATRICS,
house, the room, the clothing, the food, whether the child was
nursed or bottle-tud, If one of the eruptive fevers is suspected,
enquire whether it has had measles, or scarlet fever, and if it
has been vaccinateu. The exact onset of the disease should be
got at by going back day by day, or by enquiring if it were
well on some particular day ; then enquire into the course of
the disease and its treatment up to the date of your visit, being
careful not to ask leading questions. Having in this way
succeeded in obtaining all the information you can ‘rom the
mother, you next proceed i» examine the child yourseli, and as
this is purely objective you must observe the cry, the expres-
sion,the various spontaneous movements indicative of uneasiness,
of pleasure or pain ; the manner of sucking or drinking, whether
eagerly and with relish, or languidly, carelessly or not at all;
the enjoyment it receives from pleasant sounds, or the evident
pleasure it takes in regarding the light. You should cultivate
a habit of minute, systematic and patient investigation, and you
will thus in a little while acquire a tact and sagacity that will
not often be at fault. While you were questioning the mother
you could have been taking in at the same time the infant’s
size and development, its amount of emaciation, decubitus,
gestures, color, temperature, dryness or humidity of the skin,
the presence of eruptions or swellings. If it is below the
average size try to discover the cause of its arrested growth.
You should notice carefully the countenance as to its expression,
color, presence or absence of wrinkles from pain, emaciation or
disordered muscular action ; the appearance of the ale nasi,
and the character of the mouth. The nature of its sleep, cry,
pulse, respiration ; and lastly examine its mouth and throat, its
abdomen and the excretions.
Let us look at these points particularly :—
1. The Countenance, The complexion of a healthy baby
or young child is fresh and clear ; a loss, therefore, of its purity
al
cle
uy
an
int
pe
thi
fu
mo
wh
ig
the
afte
illn
not
and
wak
2
any!
the |
The
body
obsti
ache.
head
is in
sligh
accor
is in
side ;
accon
belly
3.
d was
ected,
1 if it
ld be
, were
rse of
being
3 way
m the
und as
»xpres-
siness,
hether
at all;
ident
Itivate
nd you
t will
nother
nfant’s
ubitus,
p skin,
ow the
rrowth.
ression,
tion or
nasi,
Pp, Cry,
oat, its
hy baby
purity
’
PEDIATRICS, 195
and clearness is one of the tirst indications of digestive
derangement ; the face then becomes muddy-looking, and the
upper lip whitish or bluish. In lardaceous disease it is pallid
and bloodless ; in cyanosis bluish. In health the face of an
infant during sleep has an appearance of comfort and content,
perhaps now and then disturbed by a gentle smile, In sickness
the features become contracted, the forehead wrinkled and
furrowed, the nostrils dilated, or pinched and thin, while the
mouth is drawn and rigid, Ina general way it may be stated
when the upper part of the face is affected some brain trouble
is the cause ; the middle of the face indicates trouble in the
thorax; and wrinkles about the chin point to abdominal
affections. Insomnia is often one of the first indications of
illness, The child may only be uneasy in its sleep, or you may
notice contractions of the brow, working of the features, tossing
and turning in bed, crying out, grinding of the teeth, or it may
wake up in a violent fright.
2. The Ory. In a healthy infant a cry is excited by
anything which causes it discomfort or inconvenience, therefore
the absence of a cry should lead you to suspect serious disease.
The cry is often accompanied by contractions of the features,
body, or limbs, which may throw light upon its cause. Violent,
obstinate prolonged crying indicates one of two things,-—ear-
ache, or hunger. In ear-ache the chiid puts its hand to its
head or presses it against its mother’s chest. Pain in the head
is indicated by a short sharp cry ; in pneumonia the pain is
slight and usually only during the cough, sad is usually
accompanied by distortion of the features ; in pleurisy the pain
is increased by moving the child or by pressing the affected
side ; the cry of intestinal pain is usually just at stool, and is
accompanied by wriggling of the trunk, flatulence, tympanitic
belly and drawing up of the legs.
3. Attitude and Decubitus. Healthy children, when
A —
z - = e ton fe cee ge =
“a 2 ° 2 or CET Te ee
RI 8 SEI A Ce oe Pe EO OE ETE? © AST A ee oe sm - —- =
196 PEDIATRICS.
awake, are always in motion, but their movements can easily be
distinguished from the constant tossing, impatient fretting and
complaining of a child that is ill. You would readily recognize
the languid hesitancy of prostration and weakness, or the still-
ness and immobility of stupor and coma.
During sleep a healthy infant or young child usually lies on
one side, and turns its head so as to bring the cheek in contact
with the pillow. If a child be found lying motionless on its
back with closed eyes and face directed to the ceiling, it is prob-
ably the subject of serivus disease, such as tubercular meningitis,
or inflammatory diarrhea. If he lies on one side with his head
greatly retracted unon his shoulder, it points to intra-cranial
disease.
4. The Pulse. In the infant it can scarcely be counted
except during sleep, and even if its rapidity can be ascertained,
the information is of little value because it is so varying, being
influenced by every movement or mental emotion. The
pulsation of the anterior fontanelle is of far more value as a test
of vigor than the pulse. In infants under a year old a sinking
of the fontanelle is a sure sign of reduction of strength ; tense-
ness and bulging is a sign of excess of fluid or hyperemia of the
brain.
5. Respiration. In new-born infants the respirations
number 40 per minute, gradually becoming less, but even after
the 2nd year they are over 20. Of more importance is the
ratio of the respirations to the pulse. Normally in the young
child they are as 1 : 3, and if they become as 1 : 2 you should
suspect pneumonia or pulmonary collapse. Frequent heavy
sighs and long pauses, during which the chest is motionless,
should lead you to suspect tubercular meningitis.
6. Temperature. In very young children is best tal-en in
the rectum, and is normally 99° F. You should never trust to
your
often
a bak
ofte1
7.
matic
you |
body
if the
or if
liver
walls.
mout
perso
T.
As
reflex
the a
the r
is ret
conse
ovale
dimir
umbi.
umbil
the n
face v
is left
silver
Yo
thoro
self,
PEDIATRICS, 197
ily be your hand, for in inflammatory diarrhoea the extremities are tl
y and often cold while the temperature rises to 104° or 105°; while in li a
gnize a baby exhausted with vomiting and diarrhea the temperature te
still- ofter sinks to 97°, .
7. General Inspection. Having obtained all the infor- iy
es on mation possible without unnecessarily disturbing the infant, i |
mtact you should strip it completely, and thoroughly examine its eee
on its body for anything abnormal. Notice if there is any eruption, ie
prob- if the abdominal veins are enlarged ; and if there is any rupture,
ngitis, or if the testicles are undescended. Feel for the edges of the
3s head liver and spleen, and the degree of tension of the abdominal
ranial §§ walls. Examine the chest with the stethoscope; then the
mouth and throat, and lastly the stools and vomica should be
personally examined.
unted
ained, TREATMENT OF THE NEW-BORN INFANT.
being
The As soon as the child is born, the cold air upon its chest by 4
aiheat reflex irritation causes the first inspiration, the thorax expands,
nking the alveoli of the lungs fill with air, the blood passes from
tenge- the right side of the heart to the capillaries of the lungs, and
of the is returned arterialized to the left side of the heart. As a
: consequence of this the ductus arteriosus contracts, the foramen
ovale closes, and the left ventricle hypertrophies. Then from
ations diminished arterial pressure in the aorta the circulation in the
after umbilical arteries ceases, while thoracic aspiration empties the
is the umbilical vein, the cord dries up from the cut surface toward
Nowa the navel, and drops off about the 5th day leaving a raw sur- q
should face which soon heals, but sometimes a button-like granulation :
heavy is left which should be cut off with scissors and touched with i
pnless, silver nitrate. i
: You should personally see that the infant’s eyes have been ig
ken 4 thoroughly washed by the nurse, and attend to the navui your-
ust to
self, for neglect of ths former may lead to troublesome is
198 PEDIATRICS,
ophthalmia neonatorum, and carelessness in regard to the latter
has resulted in fatal hemorrhage.
The first washing should always be thorough, and if there is
much vernix caseosa it should be first well smeared with lard
or oil, and some even prefer to use this alone and wipe off with
a soft rag rather than use water at all,
Asphyxia. If the second stage has been unduly long; the
head subjected to prolonged pressure ; if ergot has been injudi-
ciously used, producing tonic contraction of the uterus, closure
of the uterine sinuses, and pressure upon the umbilical cord ;
or if there has been premature separation of the} » enta, the
child may be in a more or less asphyxiated condition, the face
being swollen and livid, and the heart beating very feebly.
Treatment. If the face is very livid, allow the cord to bleed
a little ; stimulate the surface of the body by rubbing with
whiskey, sprinkle cold watez on its chest, use Sylvester’s method
of artificial respiration and put the child in a hot bath, where
it may be allowed to remain for a time.
Application to the breast should be early, just as soon as the
mother is thoroughly rested. For the first few days, until the
secretion of milk is thoroughly established, the chila should be
put at long intervals only, otherwise it is apt to irritate and
cause sore nipples. Colostrum is aperient and so obviates the
use of castor oil. After the flow of milk is fully established
the child should be put to the breast every two hours, and in.a
month or six weeks, every three hours. The mother should try
to nurse at night before retiring, so that if possible she may not
be disturbed during her sleep. Her diet should be simple but
nutritious, and she should drink plenty of milk and gruel, and
should avoid all excitement, or passion, or severe physical
exertion, Weaning of the child depends upon the onset of
teething and the condition of the mother, but should be
”
hegu
rem¢c
Se
not,
infar
SO, Ve
cache
bette
possi
invol
In
ae) ie
abser
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when
react
it is
indies
Ha
nurse
the e
A
parts
wate
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and qd
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addeq
been
or co
first
supp
latter
ere 18
lard
with
; the
njudi-
osure
cord ;
a, the
e face
bleed
with
1ethod
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til the
uld be
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2s the
lished
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ld try
ry not
le but
], and
sical
set of
ld be
PEDIATRICS. 199
begun about the 8th or 10th month, and usually it ought to be
removed from the breast entirely at the end of a year.
Selection of a Wet-nurse. Sone mothers cannot, others will
not, owing to the calls of society or business, nurse their
infants, and if they can afford to get a wet-nurse it is best to do
so, rather than bring them up on the bottle. If there is strumous
cachexia, hereditary phthisis, or great debility, it would le
better for the mother not to attempt nursing herself, but if
possible it should be insisted upon, as it promotes uterine
involution.
In selecting a wet-nurse she should be strong and heaithy,
> 9t over 35 nor under 18 years of age, and there suould be an
absence of any cachexia or diathesis. ‘The mammary glands
should be pear-shaped, firm, large veins superficially, nipples
prominent, but not too large ; theemilk should spirt out in jets
when squeezed and be of a bluish white color and alkaline
reaction You should also inspect the nurse’s child to see if
it is healthy, or if it is thin and wizzened and has “ snuffles,”’
indicating syphilis.
Hand-feeding. In some cases the inability of the mother to
nurse, her repugnance to a wet-nurse, or her inability to bear
the expense, renders hand-feeding a necessity.
A young infant should be fed with good new cow’s milk, equal
parts diluted with water, or lime water, or sometimes barley
water, and sweetened with sugar, six tablespoonfuls to be given
at a-meal, In hot weather it may with advantage be boiled,
and often a teaspoonful of cream should be added.
Sometimes when this food disagrees, a little gelatine may be
added, or some infants’ food, in which the farinaceous matter has
been converted into dextrine and glucose, may be substituted,
or condensed milk will often be found to agree better. For the
first week or two it has been estimated that a nursing mother
supplies a pint of milk to her baby in 24 hours, and that in
200 PEDIATRICS,
the later months of lactation about three pints is reached,
Therefore although infants vary in the amount of food
required, this will furnish a guide in bottle-fed babies. Goats’
and asses’ milk are better than cows’ milk if they can be
obtained, and often peptonized milk will be found to agree
where all other foods are not assimilated. After six weeks the
milk should be less diluted, and after seven months the milk
should be thickened with biscuit, arrowroot or ground rice, and
after 9 months it ought to get beef tea, broths, and when a year
old a little meat every day very finely cut or pounded.
DIRECTIONS FOR Pepronizinc MILK witH ExTRACTUM
PANCREATIS,
“Into a clean. quart bottle put a powder of 5 grains of
Extractum Pancreatis and $5 grains of bicarbonate of soda,
and a gill of water. Shake ; then add a pint of fresh milk..
“Place the bottle in a pitcher of hot water, or set the bottle
aside in a warm place for an hour or hour and a half to keep
the milk warm, about 110° F.
“ By this time the milk will become well peptonized.
“When the contents of the bottle acquire a grayish-yellow
color and a slightly bitter taste, then the milk is thoroughly
peptonized, that is to say, the caseine (or curd) of the milk
has been digested into peptone, as it is naturally in the body.
“ Partially peptonized milk has no bitter taste—has, indeed,
little apparent evidence of any change.
“Yet, in most instances, and especially for infants, it is
sufficient to partially peptonize the milk.
“ After the contents of the bottle get warm, then every moment
lessens the amount of. the indigestible ingredient of the milk.
66 T
deterr
patier
6c G
66 S
necess
place
a Vvess
may t
73 lt
chemi
the di
semala
66 P
punch
tion
accorc
I.
l.
teeth
more
is not
tution
diseas
of so
Us
increa
restles
and i
diarrh
restleg
ched,
food
oats’
n be
agree
s the
milk
, and
year
UM
yellow
oughly
- milk
dy.
ndeed,
, it is
roment
Uk,
PEDIATRICS. 201
‘The degree of peptonizing necessary in each case is best
determined by the readiness with which it is assimilated by the
patient.
“Great heat destroys, or cold checks, the digestive action.
“So, after either complete or partial digestion, it is simply
necessary, in order to prevent all further action, to at once
place the bottle of peptonized milk on ice, or put the bottle into
a vessel of boiling water, long enough to scald its contents. It
may then be kept like ordinary milk.
“It must be borne in mind that this is not a cooking or
chemical process; the object is to subject the milk to the action of
the digestive principle (the extract pancreatis) at a temperature
similar to that of the body.
‘“Peptonized milk may be sweetened to taste, or used for
punch, with rum, etc., or made into jelly ; also in the prepara-
tion of such foods as ordinarily require the use of milk ;
according to the instructions of the physician.”
I. DISEASES OF THE INTESTINAL TRACT.
1. Dentition. Perfectly healthy infants may cut their
teeth without any trouble, but in the majority there is usually
more or less local irritation and general disturbance. Teething
is not a disease, but is a delicate indicator of the child’s consti-
tutional condition, and when any hereditary predisposition to
disease exists, dentition may prove the immediate exciting cause
of some grave disorder.
Usual Course. The gums are hot and swollen; there is
increased flow of saliva ; the cheeks are flushed; the child is
restless and fretful ; its sleep is disturbed ; its appetite fails ;
and intestinal disturbances are common, such as vomiting and
diarrhoea. These symptoms may become exaggerated so that
restlessness may become e- .eme; the skin become hot and
SR ee
; |
202 PEDIATRICS.
dry ; the tongue foul ; it refuses to take the breast ; and inflam-
matory diseases of the brain and nervous system are apt to be
induced ; or there may be convulsions or diarrhea. Skin
eruptions are very apt to occur, and should be treated
cautiously at first, the more common varieties being eczema,
lichen, herpes, and erythema. Besides these complications you
may have thrush, pyrexia, stomatitis, diarrhea, pulmonary
. catarrh and otitis.
The evolution of the teeth corresponds to a similar activity
elsewhere ; thus towards the end of the first year the follicular
apparatus of the intestines is undergoing considerable deveiop-'
ment ; the cerebro-spinal system is passing through a stage of
rapid growth and high functional activity, and as most of the
organs and tissues of the body are in a state of active change,
it is not to be wondered at that the system at large s! \uld often
be profoundly affected by the process of dentition.
Treatment. The child should be kept in the open air; the
body sponged ; the gums may be rubbed; the diet should ve
simple ; the bowels regulated ; any local irritation should be
relieved, and if the gums are swollen and congested, they
may be lanced ; and lastly, constitutional disturbance should be
subdued.
2. Thrush. Popularly called “the sprue.” Is a disease
of the mucous membrane of the mouth and gullet, consisting of
white spots looking like portions of milk curd and due toa
vegetable parasite called oidiwm albicans. |
Symptoms. Before the appearance of the white spots the
mouth is red and sore, the ciild sucks with difficulty ; is fretful
and peevish ; is more or less feverish ; the bowels ae loose and
the motions greenish and acrid, so that the anus becomes
excoriated, giving rise to the expression that the disease has
“ gone through ” the child.
(
tut
cle
am
fee
bre
d inflam-
apt to be
a, Skin
treated
eczema,
jlons you
umonary
activity
follicular
deveiop-
stage of
st of the
2 change,
uld often
air ; the
hould be
hould be
ed, they
should be
a disease
sisting of
due toa
spots the
is fretful
loose and
becomes
sease has
PEDIATRICS. 203
Causes. There is usually some cachectic condition or consti-
tutional disease. It may be due to hot weather, to want of
cleanliness or indigestible food, and it is especially common
among hand-fed infants due to carelessness in the cleansing of
feeding bottles. It is rarely seen in infants suckled at the
breast.
Treatment. Correct any gastric derangement by a dose of
gray powder and rhubarb; check diarrhcea; and if there is
debility give an iron tonic. Locally use a wash of borax and
glycerine, or sodium sulphite.
3. Stomatitis. Is an inflammation of the mucous mem-
brane lining the mouth, and is partly due to the irritable
‘condition of the gums from teething, and partly to sympathy
with the digestive organs. There are three varieties : aphthous,
ulcerative, and gangrenous.
a. Aphthous. Is characterized by a vesicular eruption of
the mucous membrane of the mouth. The vesicles are of a
pearly-gray or yellowish color, varying in size from that of a
pin’s head to a millet seed, surrounded by a red areola. The
vesicles rupture in a couple of days and give rise to little
ulcers, from 2 to 20 often appearing on the lips, gum, cheek or
palate. There is usually pyrexia; the child is peevish and
refuses to nurse ; it often vomits, and the bowels are relaxed.
Treatment. Begin with a dose of gray powder, rhubarb and
soda, and if there is any cachexia, a tonic of nitro-muriatic
acid and quinine.
Locally, a wash of borax and glycerine, and if the ulcers are
slow to heal, apply silver nitrate.
b. Ulcerative. Is most frequent after two years of age, and
is found in those who are exposed to insanitary surroundings,
poor diet, and the sukiects of weakly or cachectic constitu
Phi gee EL in apead Sige ea
eet Se Ras
Se a
204 PEDIATRICS,
tion. The ulceration usually begins on the gums, which become
red, swollen, spongy, and painful. The saliva flows freely, and
the teeth often become loose.
Treatment. Attend to the sanitary surroundings and the
diet. Chlorate of potash is almost a specific and should be
given early and freely, and may be combined with iron and
glycerine,
ce. Gangrenous. “ Cancrum oris,” or noma, is a disease of the
very poor, and of strumous subjects. The face swells, a hard
spot appears on the inside of the cheek or gum, while the
tissues around become soft and cedematous. A brown slough
soon appears which rapidly spreads; the saliva is dark ; the |
breath stinks; the pulse is small; and the child becomes
rapidly weak, with hardly any fever.
Treatment, Give a gentle aperient, and try to sustain the
strength by strong nourishment, stimulants, and fresh air.
Locally, the diseased surface should be destroyed with strong
caustics, and a wash of chle“inated soda or permanganate of
potash used freely.
4. Marasmus. Infantile atrophy, or the slow wasting of
infants, is a common cause of death in hand-fed babies.
Causes. It is the consequence of insufficient nourishment,
or too much farinaceous food from which its feeble digestive
organs cannot derive even a minimum amount of nourishment,
and so it suffers from starvation. Many a child’s life is sacri-
ficed through the inability of those about it to understand that
feeding and nourishing are not the same thing. For efficient
nourishment four classes of food substances are essential, viz :—
albuminates, carbo-hydrates, fats, and salts; and furthermore,
they must be administered in such a form that they can be
easily assimilated. The only food which contains all these
elemen
besides
a more
when
clot wh
Aga
and its
the 3r¢
starch,
food to
result i
and, if
Mar:
the bre
child is
in curd
Humar
influen
the chi
Sym.
from h
sleeples
skin fle
Treo
this ‘wv:
The ch
by an
the fee
199,
5. ¢
causes |
childre
ecome
y, and
nd the
uld be
m and
of the
1 hard
ile the
slough
k ; the |
ecomes
1in the
YT.
strong
ate of
sting of
hment,
vestive
ment,
8 gacri-
hd that
fficient
viz :—
brmore,
can be
these
PEDIATRICS, 205
elements in an assiimilable form is milk. Now cow’s milk,
besides its difference in constitution from human milk, presents
a more important difference in the size and denseness of its clot
when curdled. Human miik forms a light, loose flocculent
clot which is readily disintegrated and digested in the stomach.
Again, the new-born infant has scanty salivary secretion,
and its pancreatic secretion has little effect on starch until after
the 3rd month, so that it has feeble capacity for digesting
starch. Hence, the danger of giving biscuits or other farinaceous
food to a being quite unprepared by nature to digest it,—the
result is indigestion, indicated by flatulence, vomiting, diarrhea;
and, if persisted in,—wasting from starvation.
Marasmus is seldom seen to any serious extent in infants at
the breast, unless a new-born child is put to a wet-nurse whose
child is much older, for then the milk is proportionately richer
in curd and cream, and so the young child cannot digest it.
Human milk is also very subject to diatetic and emotional
influences on the part of the mother, and so may disagree with
the child.
Symptoms, There is persistent wasting ; the child is peevish
from hunger ; at times it cries violently ; it is troublesome and
sleepless at night ; the fontanelle is depressed ; it is pale ; its
skin flabby ; bowels irregular ; and eruptions are common.
Treatment. If possible you should secure a wet-uurse, and
this will often at once arrest all the unfavorable symptoms,
The change should be preceded by a dose of castor oil, followed
by an antacid stomachic, If a wet-nurse cannot be secured,
the feeding should be carried out as directed before at page
199,
5. Gastric Oatarrh. This is one of the most common
causes of infantile atrophy, but we now speak of it as affecting
children who have passed the pexiod of infancy.
206 PEDIATRICS,
Causes. Exposure to cold ; and the ingestion of unsuitable
food. It is especially liable to occur in scrofulous and rickety
children.
Symptoms. lt may or may not be accompanied by fever.
The child is chilly, languid, swllow, dark under the eyes, loses
its appetite, vomits, bowels are costive, and it is often drowsy
or delirious,
Treatment. Begin with an emetic of vin. ipecac., and then
give a mixture of soda, bismuth, and columbo. The diet
should be restricted to milk and lime water, and in a few days
the child should have a tonic of the ammonio-citrate of iron.
6. Diarrhoea. Is especially common in childhood, and
may be of three varieties:—simple, inflammatory, and
choleraic.
a. Simple Diarrhea. Is a temporary derangement of the
bowels resulting from a mild form of catarrh.
Causes. The most common cause is improper feeding, either
because it is excessive in amount, or unsuitable; chilling of
the surface ; insufficient clothing, or dentition.
Symptoms. It is often sudden; at first the stools are fecal,
and Jumps of indigestible food are passed, and then they become
watery or greenish. Lienteric diarrhoea is when a motion is at
once caused by taking food.
Treatment. If any irritant is the cause, begin with a dose of
castor oil or rhubarb and soda. Then give a chalk mixture
with opium, catechu and sp’s. of chloroform. In lienteric
diarrhea, give lig. arsenicalis in drop doses. Green diarrhea
is thought by Hayem to be due toa microbe, and he recom-
mends a teaspoonful of a two per cent. solution of lactic acid
after every stool.
a
variety
strengt
or ente
Sym
become
and be
and fe
relieve
Trea
suckled
these ¢
water,
should
often b
powder
and if t
of liq. a
dangerq
It rung
change
Caus'
. Sym
purging
pure bi
like wa
the infl
are holl
to colla
itable
ickety
fever.
, loses
lrowsy
1 then
> diet
r days
ron.
l, and
, and
of the
either
ing of
fecal,
become
n is at
dose of
ixture
bnteric
rrhcea
recom-
¢ acid
PEDIATRICS, 207
.. Inflammatory Diarrhea. May begin like the simple
variety but soon becomes more violent and rapidly saps the
strength of the little patient. It is a severe intestinal catarrh
or entero-colitis.
Symptoms. At first like an ordinary looseness, the stools
become greenish, offensive and acid; the child rapidly wastes
and becomes weak ; the eyes become hollow ; the pulse rapid
and feeble ; there is often fever; and in a few days, if not
relieved, it may result in profound depression.
Treatment. First attend to the diet, and if the child is not
suckled at the breast you should stop the use of milk, which in
these cases acts as poison. Give cream and whey, or barley
water, or weak veal and chicken broth instead. The food
should be given cold and in small quantities. Raw meat is
often beneficial. Begin with a dose of castor oil, and then gray
powder and Dover’s powder. When the diarrhcea is checked,
and if there is much prostration of vital power try drop doses
of liq. arsenicalis or triturations of arsenic ro to viv gr.
Locally, a spiced pad is often very efficacious and agreeable.
c. Choleraic Diarrhea, or Cholera Infantum. Is the most
dangerous variety and only occurs during the summer months.
It runs a rapid course, inducing in a few hours a startling
change in the child, and often ends fatally.
Causess Hot weather, injudicious feeding, bad drainage, etc.
. Symptoms. It often begins suddenly with vomiting and
purging. It first vomits the food, then yellow mucus, and then
pure bile. The stools are watery and abundant, squirting out
like water from a syringe, and are not especially offensive like
the inflammatory variety. The child wastes rapidly ; its eyes
ave hollow ; its nose sharp ; thirst is extreme ; and it goes on
to collapse.
208 PEDIATRICS,
Treatment. Give the child a hot mustard bath, and try to
check the diarrhoea with starch and laudanum injections. It
should be allowed ice water freely ; three teaspoonfuls of iced
wine-whey, or whey and cream. The most valuable remedy is
sulphate of morphia injected hypodermically in vo gr. to a
child one year old, with five drops of ether.
The child should be kept warm by hot blankets, and hot
water bottles to its feet.
7. Dysentery. Is a disease of the] “ge intestine character-
ised by mucous and bloody stools, accompanied by pain and
tenesmus, It is frequently epidemic and is due to ulcerative
inflammation of the colon and rectum.
Treatment. Mild cases are best treated by rest, with light
and unirritating diet, and small doses of opium. If unwhole-
some food is suspected as the cause, give a dose of castor oil with
a few drops of laudanum. In the chronic form, hydrarg. bichlor.
in minute doses is good.
8. Constipation. Causes. Unsuitable diet; excess of
farinaceous food ; atony of the bowels in ill-nourished children ;
the use of soothing syrups ; or simply neglecting the calls of
nature.
Symptoms. The buwels are not moved for several days;
the complexion becomes dull and pasty; there is restlessness,
flatu‘ence, tympanitis, and furred tongue.
Treatment. Cultivate a habit in the child of regular evacue
ation, and attend to its diet. An excess of starch should be
avoided ; oatmeal may be mixed with the milk, and the food
sweetened with brown sugar. If the child is very young, soap
suppositories, and if older, enemata may be used. Cascara §
cordial, or minute doses of podophyllin are useful, and massage
may be employed to the abdomen daily with good effect.
9.
other
to it :
Cw
cough
forced
imme
obstri
effusic
adhes
can’ u
occur
Sy
violen
abdon
obstin
strain
swelli
T ré
Opiun
perist
diste
often
early,
perfo
10
(Oxy
(6).
Inhab
intest
(c).
Tenia
ry to
be AR
f iced
ady is
to a
d hot
“acter-
1 and
rative
1 light
whole-
il with
ichlor.
ess of
dren ;
alls of
days ;
Ssness,
evacil:
ld be
e food |
B, Soap
ascara §
assage
PEDIATRICS, 209
9. Intestinal Obstruction. Is rarely due to any
other cause than intussusception.
Babies are especially prone
to it during their first year.
Causes. Drastic purgatives; indigestible food; violent
coughing ; or falls and accidents. One part of the bowel is
forced or invaginated fiom above downwards into the part
immediately continuous with it, the consequence of which is
obstruction of the canal and of the circulation of the intestine ;
effusion of blood and lymph takes place, giving rise to
adhesions, and if complete, gangrene may result. <A swelling
can’ usually be seen or felt in the abdomen over it. It may
occur in the small intestine or in the colon.
Symptoms. The child suddenly screams, turns pale, cries
violently, writhing and drawing up its legs as if in great
abdominal pain which comes on in paroxysms. The bowels are
obstinately confined, and a little blood is usually passed with
straining, and it vomits all food. After a time a distinct
swelling can usually be felt deep in the iliac fossa,
Treatment. Its eavly recognition is of great importance.
Opium should be given at once to ease the pain and arrest
peristaltic action. An enema may be tried, but it is best to
distend the bowel with air as completely as possible, and this
often relieves the pain and unfolds the intussusception if done
early. All means failing, it may be advisable in some cases to
perform laparotomy.
10. Intestinal Worms. (a). The Small Thread Worm.
(Oxyuris Vermicularis) is found in the cecum and rectum.
(6). The Long Rownd Worm. (Ascaris Lumbricoides).
Inhabits the small intestine, but migrates to all parts of the
intestinal tract.
(c). The Tape-Worm. Tenia soliwm, derived from pork, and
Tenia medio-cannellata from beef.
210 PEDIATRICS.
When the ripe joints are swallowed by some animal such as
a pig or cow, the eggs and embryos, cal!cd pro-scolices, escape,
and penetrating the tissues enter the muscles, liver, or brain,
becoming a cystocercus or bladder-worm. This swallowed in
partially cooked pork or beef develops in the human system
into the perfect tape-worm.
Symptoms of Worms. Itching of the nose, pruritus ani,
abdominal pains, variable appetite, fever, vomiting and
diarrhea, or convulsions, are a group of symptoms often point-
ing to worms, but the only sure indication is to find either the
worms or their ova in the evacuations.
Treatment. The small thread worm is best tre.ted by rectal
injections of salt and infusion of quassia , the long round worm
by santonin ; and the tape-wcrm by ext. male fern, turpentine,
or Tanret’s pelleterine.
II. DISEASES OF THE NERVOUS SYSTEM.
1. General Symptoms. In the young child there is
excessive excitability, so that a slight irritant may give rise to
symptoms out of all proportion to the cause. In every acute
illness the nervous system shows signs of distress; thus, in
acute indigestion the skin is hot, the child is restless, cries, is
often delirious, twitches in its sleep, or may have convulsions.
There are certain symptoms, however, which point directly to
disorder of the nervous system.
Squinting, although not always a sign of brain disease,
should alwavs excite alarm.
Nystagmus, or rolling of the eyeballs, often indicates brain
disease, especially tubercular meningitis, hydrocephalus, or
brain tumor.
The condition of the pupils is of importance. They are
usually contracted during sleep, and dilated when the child is
ich as
scape,
brain,
red in
ystem
3 anil,
and
point-
r the
rectal
worm
ntine,
I.
ere is
ise to
acute
us, in
‘ies, is
[sions.
PEDIATRICS. 211
awake, They are contracted from opium and in the early stages
of meningitis ; in the later stages of meningitis, and in other
cerebral diseases, they are dilated.
Impairment or loss of sight points to brain tumor, meningitis,
or thrombosis.
Delirium often occurs in digestive derangements ; in alter-
ations of the blood, as in acute specific fevers; in the early
stage of croupous pneumonia ; and in serious brain affections.
Drowsiness, while it occurs in brain affections, may occur in
pneumonia, fevers, etc.
Changes of temper ; tremors ; spasms; paralysis ; vomiting,
independent of food; and constipation, often point to cerebral
disease.
2. Convulsions. Are common in children, especially
during the first two years, and depend upon exalted excitability
of the reflex centres in the pons and medulla.
Causes. They may occur in utero, and many of those cases
of death and paralysis of new-born infants are due to convul-
sions. The liability to this condition often runs in families, or
in individual members of families, and in rickety children.
~
They may be due to reti::.s causes, such as injuries to the skin,
as burns; to irritation of the alimentary canal, as from
indigestible food, or worms ; to irritation of the gums from
teething ; to inflammation of the ear ; retention of urine ; sud-
den chilling of the surface of the body ; violent emotions, as
terror; to the onset of some acute illness ; to anemia of the
brain from loss of blood ; or to uremia.
Symptoms. They may come on suddenly, or be preceded
by symptoms of nervous excitability spoken of as ‘inward
212 PEDIATRICS,
fits.” When the fit sets in the child gets stiff; its head is
retracted ; its arms and legs become rigid; the eyes turn up;
and the breathing is labored. Then cleuic spasms come on ;
the muscles of the face work ; the tongue is bitten ; there is
twitching of the legs and whole body ; and often frothing at the
mouth. It is more serious if limited to one side, as it indicates
a cerebral origin. A persistent squint; convulsions without
ioss of consciousness ; and persistent stupor after the convul-
sions all point to organic disease. The congestion of the brain
from convulsions due to some reflex cause, if persistent or long
continued, may lead to organic cerebral disease.
Prognosis. If due to organic disease the upshot is unfavor-
able; but if owing to some reflex cause, the older the child and
the shorter the attack, the less danger, although in any case it
is always dangerous and alarming.
Treatment. Waste no time in seeking for the cause, but at
once put the child in a hot bath and apply sponges soaked in
cold water to the head. If this does not arrest it, give a whiff
or two of chloroform, which will usually quiet the fits, and then
seek for the cause and if possible remove it. If due to an
overloaded stomach, give an emetic of vin. ipecac. ; if the bowe!s
are loaded, use an enema; if teething, lance the gums; if
inflammation of the ear, syringe with warm water, or apply a
poultice ; if due to uremia, give pilocarpine. To prevent a recur-
rence, give chloral in gr. 2 doses repeated frequently to a child
under one year, or else pot. brom., and then improve the general
condition, attending to the diet and giving tonics or cod-liver
oil if indicated.
3. Hydrocephalus. This is serous effusion into the
cavity of the skull and may be congenital or acquired.
Causes. It is often due to drunkenness or syphilis on the
ad is
Up ;
on ;
sre is
at the
icates
thout
nvul-
brain
r long
favor-
d and
ase it
out at
ed in
_ whiff
1 then
to an
0We:S
ns ; if
pply a
recur-
4 child
eneral
d-liver
o the
on the
PEDIATRICS, 213
part of the parents; or it may be the result of rickets or
anemia.
Morbid Anatomy. When congenital, the walls are pressed
out, and the head becomes distended; the frontal bones are
prominent, the sutures are widened, and the fontanelles dis-
tended.
Symptoms. The children so affected often die during delivery,
and usually within the first two years. The eyes protrude;
the head is heavy ; the muscular system is not developed ; as
a rule intelligence is backward, while sight and hearing are
often impaired ; and nervous symptoms are common, such as
headache and convulsions.
Treatment. Little can be done except to regulate the bowels
and diet. Hydrarg. bichlor. may do good, and strapping the
head with ung. hydrarg., or ung."potass. iodid. may be tried.
4. Tubercular Meningitis. Is an inflammation of the
meninges at the base of the brain, and may occur at all ages.
Causes, The tubercular diathesis, the exciting causes being
injury to the head, exposure, or overstudy.
Pathology. Engorgement of the meninges and vessels of the
pia mater is found, together with ventricular effusion, and a
deposit of gray miliary tubercle at the base of the brain.
Symptoms. The child is thought for some time not to look
well. It is thinner, paler, and listless. A change of character
is often noticed, and there is headache and vertigo. The
temperature is often slightly elevated. Then severe headache
sets in, with vomiting independent of taking food, and obstinate
constipation. The headache is severe, frontal, in paroxysms,
and is increased by any movement, or by light. The tongue is
214 PEDIATRICS.
not usually coated, and the child takes early to its bed. The
abdomen is soft, compressible and doughy ; the pulse is usually
slow ; the breathing is irregular, and sighing; the pupils are
first contracted, and then dilated ; and light is painful to the
eye. These symptoms steadily go on and become intensified,
until coma, convulsions, and paralysis result, The average
duration is 12 days.
Treatment. Should be one of prevention, although potass.
iodid., or iodoform in } to 4 gr. doses, may be tried. An ice
bag may be applied to its head, and a purgative should be given,
but these cases are usually hopeless.
5. Acute Infantile Spinal Paralysis. (Anterior Polio-
myelitis).— Pathology. Is an inflammation of the anterior
cornua of the spinal cord, producing changes in the gray matter
itself, in the roots of the nerves springing from that situation,
and in the muscles, tendons, bones, and joints to which they are
distributed.
Symptoms. The attack is sudden, the paralysis reaching its
height at once. The child goes to bed and wakens up with its
limbs motionless. It may affect one muscle, or a group of
muscles, one limb, or al). After some weeks, or months a
partial recovery is the rule, but wie muscles atrophy, and
paralytic contractions occur, giving rise to club-foot, etc.
Prognosis. It is not fatal, and some cases recover completely,
others partially. Electricity is of great importance in determ-
ining the result. Thus, every muscle which does not react to
the faradic current after the lapse of a fortnight is likely to be
permanently disabled. Again, the muscles which have lost all
physical connection with the spinal cord, no longer respond to
the faradic current, while they react to slow interruptions of
the constant current, This is called the reaction of degener-
ation.
Tre
count
and as
the fa
place
tions.
and k
tonics
6.
affecti:
with a
someti
cribed
Syn
wantitr
over, a
charac
should
spinal
quence
the ex
positio
becom¢
other 1
helpleg
Tred
used, v
necesse
The
ally
are
the
fied,
rage
tass.
| ice
ven,
olio-
rior
itter
‘ion,
rare
y its
a its
» of
iS a
and
ely,
orm-
st to
0 be
t all
| to
s of
ner-
PEDIATRICS. 215
Treatment. Quiet, and rest in bed; a brick purgative;
counter-irritation to the spine; a diet of milk and broths ;
and as soon as any recovery of power is noticed, but not before,
the faradic current should be used daily. If no response takes
place you should try the constant current with slow interrup-
tions. The paralyzed limb should be wrapped in cotton batting
and kept warm ; friction and massage should be employed ; and
tonics of iron and strychnia.
6. Pseudo-hypertrophic Paralysis. This singular
affection, in which extreme feebleness of the muscles is combined
with an appearance of extraordinary development and vigor, is
sometimes spoken of as Duchenne’s disease, as he first des-
cribed it.
Symptoms. The spring, so marked in healthy children, is
wanting, and it feels ‘avy to lift. It can easily be pushed
over, and has diffict...» in rising. It soon has to stand with a
characteristic attituc: ‘he legs widely spread out, and its
shoulders thrown backward, exaggerating the antero-posterior
spinal curvature, and the belly protrudes. This is the conse-
quence of weakness of the extensors and flexors of the hip, and
the extensors of the knee, muscles which maintain the upright
position in walking. In about a year the calves of the legs
become enlarged, and a similar change takes place in all the
other muscles, As the paralysis extends the patient gets more
helpless, and seldom lives long after puberty.
Treatment. Very little can be done, Faradization may be
used, with arsenic and phosphorus internally, while it may be
necessary to employ mechanical supports.
Be
216 PEDIATRICS.
Ill. DISHASES OF THE RESPIRATORY SYSTEM.
1. Examination of the Chest.
A.—Puysicat Siens oF Diseases or THE Lunes.
Physical Signs are elicited by the following means :
I. Inspection, by which we learn the form, size and move-
ments of the chest. ;
II. Mensuration is the measurement of the chest by the tape
line or by the spirometer, to ascertain the amount of air the
lungs are capable of receiving.
III. Palpation or the application of the hand is used for
the same purposes as in other parts of the body and to ascertain
the presence of “ vocal fremitus ;” or “fluctuation,” and to con-
firm the results obtained by Inspection and Mensuration.
IV. Succussion is employed to detect thoracic fluctuation
by gently but abruptly pushing the patient’s trunk backwards
and forwards and listening.
V. Percussion may be mediate or immediate :
(1) Diminution of Clearness to any degree of dulness is
caused by effusion, congestion, condensation and cedema.
(2) Increase of Clearness is caused by pneumothorax,
atrophy, hypertrophy and emphysema of the lung.
(3) Tympanitic Sound indicates the presence of quantities of
air contained in cavities whose walls are yielding but neither
very tense nor very thick. It may be of various kinds.
(a). Simple.
(b). Amphoric Resonance and “ metallic tinkling” is similar to
that obtained on striking a wine cask when partially or entirely .
empty.
action
of oth
(
caused
deficie
effusic
apex 1
persor
(
in get
the cel
or froi
move-
e tape
ir the
d for
ertain
0 con-
jation
wards
ess is
10rax,
ties of
pither
ilar to
tirely
PEDIATRICS. 217
(c). Tubular Sound is heard when any condition exists which
brings the larger bronchial tubes unnaturally near the surface,
or when any sound-conducting substance is present between
the bronchi and surface.
(d). The bruit de pot felé or “cracked pot sound” is heard
when a cavity exists in the lungs having thin elastic walls and
a free communication with the bronchial tubes.
VI. Auscultation may also be mediate or immediate. In health
two sounds are heard, viz.: the Tubular or Bronchial sound
and the Pulmonary or Vesicular murmur.
These are altered by disease or new sounds are heard.
1. Changes in the Vesicular Murmur :
(a) As to Intensity.
(a) Increased, or puerile breathing, depends on an increased
action of the air cells, usually to make up for deficient action
of other parts.
(8) Diminished—more noticeable in inspiration—may be
caused by anything which obstructs the passage of air; by
deficient respiratory action, owing to debility or local pain; by
effusion ; or deposit of tubercle.
(y) Absent, caused by continued furtherance of above
causes.
(b) As to Rhythm.
(a) Jerking respiration is only corroborative if heard at the
apex in tubercular deposit, as it is so often heard in hysterical
persons.
(8) Prolonged expiration denotes that the air has difficulty
in getting out of the lungs, and is owing to loss of elasticity of
the cells from over-distention (clearness) ; or deposits (dullness) ;
or from an obstruction in the bronchi.
218 PEDIATRICS.
(c) As to Character.—In health the vesicular murmur is
characterized: by its softness. Any affection which causes the
sound in the bronchi to be produced with greater intensity, or
to be better transmitted, will occasion harsh breathing, as when
the bronchial membrane is swollen, as in Bronchitis, or when
there is compression of the lung tissue with partial condensa-
tion, as in Phthisis and Pneumonia.
2. Changes in the Bronchial Sound.
Here the character is of more importance than rhythm or
intensity.
To hear well defined bronchial respiration is mostly to
meet with complete consolidation of the lung tissue, as in tuber-
cular infiltrations and hepatization of the lung.
Varieties of Bronchial respiration are :
(a) Cavernous Respiration, where a cavity exists.
(6) Amphoric Respiration is indicative of a large cavity with
firm walls.
3. New or Adventitious Sounds.
(a) Rales are sounds generated in the air tubes by the pass-
age of air through them when contracted or containing fluid.
They may be:
(a) Dry.
(i) Sibilant Rhonchus (in small tubes) is a hissing, whist-
ling or wheezing sound heard in certain stages of Catarrh and
Bronchitis.
(ii) Sonorous Rhonchus (in large tubes) is a snoring or dron-
ing hum. Less dangerous than sibilus.
(iii)
Heard
(8)
(i
(ii
(ii
©)
but is
heard i
4. T
(a) J
tissue ¢
monia ¢
(b) L
a cavity
sound.
(c) G
due to t
bet weer
1. Pe
Pleuriti
sensatia
2. Dy
»by bodil
by tumo
is * Ort!
aur is
es the
ty, or
when
when
Jensa-
im or
ly to
uber-
with
pass-
PEDIATRICS. 219
(iii) Dry, Crackle. Like sound of blowing into a dry bladder.
Heard in emphysema.
(8) Moist, caused by air bursting through a liquid in tubes.
(i) Small Crepitation or subcrepitant rales.
(ii) Large Crepitation or Mucous rales.
(iii) Gurgling is merely rale of cavities.
(6) Friction Sound attends both movements of respiration,
but is loudest and most prolonged during inspiration. Best
heard in Pleuritis.
4. The Voice and Cough, “ Vocal Resonance,”
(a) Bronchophony denotes increased density of Pulmonary
tissue caused by pressure or by deposit, especially in Pneu-
monia and Phthisis.
(6) Pectoriloguy caused by condensation of the lung around
a cavity communicating with a bronchus. Hollow cavernous
sound,
(c) @gophony is a bleating variety of Bronchophony. It is
due to the presence of pleuritic effusion, or a thin layer of fluid
between compressed lung and ear.
B.—RatTIoNAL SIGNs.
1. Pain is a symptom of very little value by itself. In
Pleuritis you have a severe sharp pain; in Pneumonia the
sensation is a burning one.
2. Dyspnea may be caused by exertion in weak persons ;
.by bodily or mental excitement ; by pressure upon the lungs as
by tumors, ascites, and pregnancy. The most aggravated form
is “ Orthopneea.”
220 PEDIATRICS.
3. Cough may be present when no disease exists in the lungs
but there is very seldom any affection of the lungs without a
cough. May be,
(a) Dry Cough, which is indicative of irritation caused by
very many causes and usually precedes
(b) Moist Cough which is usually accompanied by free
expectoration.
In Bronchitis you have a loud ringing cough; in Pleuritis a
small suppressed cough ; in tubercle a small dry hacking cough
usually most troublesome in the morning; in Pneumonia a
slight small cough.
4, Hepectoration is mucous and free in Catarrh and Bron-
chitis ; purulent in severe Bronchitis and Phthisis; rusty in
Pneumonia ; lumpy and muco-purulent in advanced Phthisis ;
suddenly and largely purulent in bursting of an abscess ; in
Pulmonary Gangrene w stinking sputa, etc.
(c) Constitutional Signs.
Constitutional signs are those which affect the system at
large. They are fever, night sweats, accelleration of pulse, ema-
ciation, loss of strength, loss of appetite, etc.
The examination of a child’s chest requires gentleness and
tact, It should be stripped to the waist,
Inspection. In thechild respiration is chiefly diaphragmatic,
so that forcible movement of the thoracic walls is a sign of
labored breathing, and one of the indications of broncho-
pneamonia, Great recession of the lower part of the chest or
epigastrium is an indication of some obstruction in the larynx.
If the chest is laterally grooved it indicates softening of the
ribs fi
than t
Pal
but vc
pitche
rapidl;
often
ascerté
enced
nearer
lower,
higher
space,
The
as the
Per
exerci:
resona
The d
itis d
ance,
ing th
area (
“ crac)
percus
Aus
smalle
area 1
and h
inexp
tion ;
lungs
out a
sed by
free
ritis a
cough
nia a
Bron-
asty in
thisis ;
ss; in
em at
2, ema-
33 and
matic,
ign of
oncho-
est or
arynx,
of the
PEDIATRICS. 221
ribs from rickets, There may be more mobility on one side
than the other,
Palpation. The movement of the chest can be made out,
but vocal fremitus is not so marked as in the adult, for the high
pitched notes of the child’s larynx succeed one another too
rapidly to be readily perceptible by the hand, Fluctuation can
often be detected when there is effusion, You should always
ascertain the exact site of the heart beat, as it is greatly influ-
enced by effusion in the chest. In young children it is always
nearer to the nipple than in adults, and as the latter is always
lower, and the heart itself relatively smaller, the apex beat is
higher than in adults, being usually found in the fourth inter-
space.
The exact position of tae liver and spleen should be noticed,
as they may be pushed down by effusion.
Percussion. If your hands. are warm, and gentleness is
exercised there is seldom much opposition. There is greater
resonance than in the adult, and this often obscures dulness.
The degree of resistance is also important, thus in pneumonia
it is dull, and in pleuritic effusion there is still greater resist-
ance. It is always best to use two or three fingers in percuss-
ing the child’s chest as the sound is collected from a larger
area of lung than if one finger only were employed. The
‘cracked pot” sound is always heard in a child if the chest is
percussed during expiration, or with the mouth open.
Auscuitation, Always use a stethoscope because the chest being
smaller it is more important to limit as narrowly as possible the
area under investigation. The vesicular murmur is coarser
and harsher (puerile), and so is apt to be mistaken by the
inexperienced for disease, especially at the apices, and expira-
tion is often prolonged without any disease being present.
222 PEDIATRICS,
Conduction of sounds from the pharynx and trachea to the
apices is common, so that the breathing there is often loud,
hollow, or blowing, and still does not indicate disease, Weak-
ness of vesicular m irmur is very important.
Bronchial, cavernous, and amphoric sounds are the same as
in the adult, but the morbid process is usually a step in
advance ; thus cavernous respiration is often a sign of mere
consolidation,
Be sure to thoroughly and particularly examine the Lack of
the lungs in children.
2. Laryngismus Stridulus, or false croup, is a catarrh
of the larynx with superadded spasm.
Causes. It is rare before two years of age, and is most
common between 2 and 7. It is more frequent in boys than
girls, and is apt to recur,
Symptoms. The child may go to bed well, and wakens up
about 12 o’clock with a hoarse, barking, sonorous cough, and a
loud whistling stridor in his breathing, this being confined to
inspiration, while the expiration is short and comparatively
noiseless. The movements of the chest are labored and
violent ; the nares dilate ; the eyes are staring ; and the child
has a terrified expression. The seizure lasts from a few
minutes to half an hour, gradually subsiding, and the child falls
asleep.
Diagnosis. ‘The sudden invasion; the voice is not sup-
pressed ; the cough is loud and not muffled; the stridor is
marked in inspiration ; there are no enlarged cervical glands ;
and there is an absence of albumen in the urine,
Prognosis. Is favorable, death very seldom occurring.
Treatment. Put the child in a warm bath and give an
emetic of vin. ipecac. A cold wet cloth to the larynx often
acts magically. Then give chloral to prevent a rel .pee.
ea to the
‘ten loud,
. Weak.
@ same as
. step in
1 of mere
» Lack of
a catarrh
1 is most
boys than
akens up
gh, and a
nfined to
paratively
yred and
the child
m a few
child falls
not sup-
stridor is
1 glands ;
PEDIA ‘RICS,
3. Diphtheria is a specific, infectious and contagious dis-
ease, characterized by inflammation of various mucous surfaces
and the formation on them of a more or less tough and leathery
false membrane. It often follows some zymotic fever such as
measles or scarlutina ; it probably has a pythogenic origin ; it
has no proper eruption, although sometimes it has one like
scarletina, to which disease it seems to be closely allied; and
lastly, one attack does not protect against another.
(a) Pharyngeal Diphtheria.
Symptoms. There is usually a stage of incubation of a day
or two ; then there is languor ; slight elevation of temperature ;
some difficulty in swailowing; the breath is fetid and the
tongue thickly coated, and there is albuminuria. On examin-
ing the throat one or more patches of a tough, dirty grayish-
white material are seen, which are usually not confined to the
tonsil but extend to the soft palate or uvula, and cannot be
removed by mere swabbing as can be done with the exudation
in follicular quinsy. The cervical glands become enlarged and
tender early in the disease, and very soon there is more or less
prostration according to the severity of the attack,
Pathology. lt is due to a germ, probably a variety of
micrococcus, which is introduced froin without by direct con-
tact, generally fixes itself on the fauces or larynx and becomes
generalized from that point.
(6) Laryngeal Diphtheria.
When the inflammatory process attacks the larynx it is
spoken of as membranous croup. There is still a difference of
opinion as to the identity of croup and diphtheria. Those who
hold that they are different affections say that croup is a
sthenic disease, while diphtheria is asthenic ; in croup the urine
is not albuminous, but it is in diphtheria ; croup is not followed
by paralysis, while diphtheria usually is ; croup is neither epi-
224 PEDIATRICS.
demic nor contagious, while diphtheria is both. Now these
distinctions do not always hold good, indeed they are converti-
ble, and while there may be reasons for believing in the possible
existence of a non-specific membranous croup, still as it is
impossible to distinguish between them with any certainty, and
the question of contagion is involved, it is always best to treat
every case on the assumption thet it is diphtheritic. The very
fac. that many surgeons have contracted diphtheria by sucking
a tube where tracheotomy had been done in a case of supposed
simple membranous croup, ought to convince anyone of their |
identity.
Symptoms. There may or may not have been previous exu-
dation in the fauces, and the preceding symptoms may have
been slight, when suddenly the breathing is noticed to be
stridulous, respiration becomes harsh, the cough, voice and cry
are hoarse. This lasts from a few hours to a few days becoming
more marked until dyspnoea and cyanosis set in unless relieved.
Sequelae of Diphtheria. These are albuminuria and paralysis.
Albuminuria is a constant symptom and is present early in
the attack. Itis not like that of scarletina in which albuminuria
is a late symptom, the urine contains blood and casts, is accom-
panied by dropsy, and the kidney is in a condition of inflamma-
tion.
Paralysis occurs usually two or three weeks after an attack
of diphtheria, and shows itself first by a peculiar alteration of
the voice and difficulty in swallowing due to paralysis of the
palate musci2s. It isa symptom which often leads to the detec-
tic. of a hitherto unsuspected disease. The paralysis may
extend to the ciliary muscle and affect accommodation ; or to
the muscles of the eyeball causing squint; or i+ may affect the
muscles of the body and extremities giving rise to a peculiar
attitude and gait.
durin
it mé
scarle
Sy
cougt
There
bubbl
the cl
(capil
monis
restle
w tiese
onverti-
possible
us it is
ity, and
to treat
he very
sucking
Ipposed
of their |
US EXU-
iy have
1 to be
and cry
coming
elieved.
aralysis.
early in
minuria
accom-
flamma-
b attack
ation of
s of the
2 detec-
is may
3 or to
fect the
peculiar
PEDIATRICS, 225
Modes of Death. Diphtheria may destroy life by blood
poisoning ; inhibition of the heart’s action ; asthenia ; or laryn-
geal extension with its consequences,—asphyxia, etc,
Treatment. Every means should be taken at once to prevent
contagion. The strength should be sustained by a stimulating
diet. Iron, quinine, and potass. chlor. should be given intern-
ally. Locally a spray of hydrarg. bichlor. and sulphurous acid
should be used every hour or two, and the patches may be
gently removed, and a saturated solution of boracic acid in
glycerine applied several times a day by means of a camel’s hair
brush. Some prefer chloral solution, iodized phenol, or iron
and glycerine.
In the laryngeal variety the steam spray is beneficial, and
tracheotomy or intubation of the larynx may be indicated in
some cases.
4. Bronchitis is a disease which is common in children,
and not only dangerous in itself but in its tendency to run into
broncho-pneumonia or pulmonary collapse.
Causes. It is brought on by damp and cold. It may occur
during teething ; from irregularities in diet ; from worms ; or
it may cc-uplicate measles, whooping-cough, typhoid fever,
scarlet fever, diphtheria, and diseases of the heart and kidneys.
Symptoms. It usualiy begins with coryza, sneezing and
cough. The cough is at first hard and soon becomes soft,
There is no dulness on percussion, and auscultation determines
bubbling and squeaking with sonoro-sibilant rhonchus all over
the chest. If the inflammation extends to the smaller tubes
(capillary bronchitis), or alveoli of the lung (broncho-pneu-
monia), the symptoms become very alarming ; the child becomes
restless; great dyspnea ; face livid and expression of distress ;
16
an
Oe
SNe ee ee re
eo
= pte
= pro ee eae oe
Sais
ass
ioe
226 PEDIATRICS.
pulse quick and feeble. Dulness, and subcrepitant rales are
heard especially at the back of the lungs.
Chronic Bronchitis is common in children five or six years of
age, especially those of a scrofulous tendency, and is very apt
to lead to emphysema.
Treatment of Bronchitis. Never neglect a cough in a child,
but if feverish at once put it to bed, a poultice with a little
mustard Should be applied to the chest, and a febrifuge expec-
torant given. If capillary bronchitis or broncho-pneumonia
sets in give stimulating expectorants and an emetic of ipecac,
Opium should be very cautiously used as it is apt to dry up the
secretions.
In the chronic form liquid tar, counter-irritants, and change
of air are indicated.
4. Preumonia may be croupous or catarrhal.
(a) Croupous. Is rare in infancy up to the end of the
second year, after that catarrhal and croupous are equally
common, and with each succeeding year it is more and more
likely to be of the croupous variety.
Of late years there has been a growing tendency to look
upon croupous pneumonia as an acute general disease of which
the pulmonary consolidation is the anatomical expression, and
no longer to regard it as a mere local inflammation. Some
have compared it to acute rheumatism and tonsillitis, while
others look upon it as a specific fever and class it with typhoid.
That it is a general disease with marked local manifestations is
shown by the fact that the general symptoms are not propor-
tionate to the extent of lung involved ; they precede several days
any evidence of local mischief, and the highest temperature is
often reached before the point of most complete consolidation ;
while the head symptoms, the sweating, the herpetic eupte
and the exudation are peculiar.
les are
ears of
ary apt
, child,
a little
expec-
lmonia
ipecac,
up the
change
of the
qually
1 more
0 look
which
ym, and
Some
while
rphoid.
ions is
propor-
al days
ture is
ation ;
ption,
PEDIATRICS, 227
Symptoms. Are like those of the adult but are often ushered
in with convulsions.
(6) Catarrhal. Broncho-pneumonia is nearly always a
secondary affection resulting from the spread of inflammation
from the bronchial mucous membrane to the alveoli, and so it
invariably attacks both lungs.
Symptoms. It is always preceded by pulmonary catarrh ;
more or less fever ; cough, which is short and hacking ; the
face is more or less livid ; the labial line is marked ; the pulse
respiration-ratio is perverted ; respiration is labored, and
dyspnea or even orthopnea are common. The paroxysmal
cough of bronchitis changes to the short hard hacking cough of
pneumonia, which usually causes great distress and exhaustion.
Physical Signs. At first are heard only the signs of bron-
chitis, for the consolidation being limited to small scattered
nodules surrounded by emphysematous air cells can rarely be
detected by percussion. Auscultation determines crepitant
rales and rhonchus, and unlike croupous pneumonia the rales
are not lost when consolidation occurs. As the nodules of
consolidation grow larger and coalesce, respiration becomes
more labored, cyanotic symptoms appear, and if the child is not
relieved it becomes exhausted, sinks and dies. Before this,
there is more or less dulness at the back of both lungs, and
tubular breathing is heard. There is seldom any dulness in
front. Lastly, should a favorable termination occur, there is
not the critical fall of temperature seen in croupous pneumonia,
but the symptoms gradually abate as well as the physical signs.
Diagnosis. One of the greatest difficulties is to exclude
phthisis.
Prognosis is always doubtful, and the mortality is very
large in infancy.
228 PEDIATRICS.
Treatment. It may often be prevented by the judicious
management of the preliminary bronchitis. Begin with an
emetic of ipecac, linseed and mustard to the back of chest,
stimulants early, and sustain the strength by nourishing diet.
6. Pleurisy is comparatively rare during the first year,
more common during the second year, and after that is one of
the most common diseases met with in childhood, It is seldom
fatal. The effused fluid is apt to become purulent at an early
period.
Symptoms. It usually sets in with a chill, then fever and a
slight cough; a pain in the side, causing the child to cry
violently when pressed in the side; but it usually subsides as
the effusion sets in, and this soon turns to pus, constituting
empyema.
Physical. Signs. It is difficult to distinguish it from croup-
ous pneumonia. Palpation detects fluctuation. On percussion
there is increased dulness with resistance like that on percuss-
ing a thick block of wood, and the alteration of note is got by
change of position. By auscultation a friction sound is heard
which is peculiar, being crackling or crepitating but very super-
ficial. The heart may be pushed over to the right nipple by
the effusion.
Treatment. Put the patient in bed and at absolute rest ; a
light diet ; febrifuge ; and opium for pain. Apply cotton batting
to chest with a bandage. Potass. iodid. three or four times a
day may be given later, and if pus is detected, and verified by
hypodermic syringe, it is best to make a free incision with
antiseptic precautions, and after carefully evacuating a portion
of the pus, an antiseptic dressing should be applied and changed
daily, allowing more pus to escape gradually.
PEDIATRICS, 229 ba
ious
i IV. DIATHETIC DISEASES. Me
hest, Hi
diet. 1. Scrofula. Is the most common of the morbid types of |
constitution ; affects all ranks; is found in all part of the i
ear, world ; is often hereditary ; and is very persistent. Its evi- f i
e of dences are widespread throughout the body, attacking the skin, ;
Idom the mucous membranes, bones, joints, organs of special sense, i
arly lungs, and the lymphatic glands. All these parts are exceed- Hf
ingly sensitive, and may be attacked with some obstinate or i
ree even incurable form of the disease. They occur early, so that i
scrofula is especially a disease of childhood, being found more
ony especially from the 3rd to the 14th year, after which its ravages
aay usually abate.
ting
Besides actual scrofulous disease, other circumstances deter-
mine it in the child, such as cancerous, tubercular, and syphilitic
roup- cachexie ; age in the father; imperfect nutrition in the mother
ssion during gestation ; marriage of cousins ; insanitary surroundings
"cUss- in the child; neglect and bad food ; or lastly, it may be the
ot by result of measles, whooping cough, variola or scarletina.
heard Symptoms. In a well marked case it is expressed in the
ee build and general appearance of the child. It is stout, heavy,
ia y and looks older than its years ; the face is broad and flat ; the
upper lip thick ; the nose wide and its bridge sunken ; the ends
a of the bones are thick ; and the limbs are soft and flabby.
whe 5 Some scrofulous children are delicate; and the skin thin and
transparent.
nes a
od. by In a scrofulous constitution there is a tendency to rapid
with proliferation of all the epithelial and cellular elements of the
rtion body. The lesions are inflammatory in their nature, and
nged characterized by rapid cell growth, and rapid decay of the new
formed elements. Diseases, therefore, of this nature, show their
constitutional origin by their tedious course; their sluggish
OO EEEaEa——e
230 PEDIATRICS,
response to treatment; their origin from some trifling cause ;
and their proneness to relapse. Wherever the lesion is, the
glands are liable to suffer, and this is so generally recognized
that in a popular sense scrofula means simply a chronic
enlargement of glands with a tendency to suppuration.
(a). Mucous Membranes are especially sensitive in strumous
children, and they are very liable to catarrhs. Gastric catarrh
is common and differs from that in healthy children by being
always accompanied by fever. Intestinal catarrh is apt to lead
to ulceration, and so become chronic. Catarrh of the nasal
passages is usually accompanied by excoriation of the upper lip,
and is apt to lead to ozcena and destruction of the bone, especi-
ally if it occurs in a child over two years of age. It is apt to
be syphilis in a younger child. If it attacks the eyelids it
results in tinea tarsi; or the eyes, it gives rise to pustular
ophthalmia and keratitis, indicated by lachrymation and photo-
phobia. If it is a girl you may find vulvitis.
Pharyngeal catarrh is very common, leading to enlargement
of the tonsils and deafness, Otorrhcea and otitis are common.
Pulmonary catarrh is apt to become chronic and give rise to
what is commonly called “ winter cough.”
(5). Skin. Scratches are apt to fester, and acute eczema is
common in scrofulous children. Small lumps often appear on
the legs, arms, or abdomen, at first hard and movable, soon
become fixed, inflamed, and suppurate, containing a cheesy-like
pus.
(c), Bones and Joints. Caries of the vertebree is very frequent,
and disease of the tibia.
(2d). Lymphatic Glands, Enlargement of cervical glands is
most common, but the bronchial and mesenteric are often also
affected. They do not always suppurate.
Tre
atten:
Todid
preve:
cadm:
2.
on th
lymp.
It.
(a)
patch
(5)
whicl
(c)
osteu
of th
Sy
syste
may
cause
but i
body
a hos
the
herec
“snv
ulce
color
exter
and
the 1
oon
like
ent,
3 is
also
PEDIATRICS. 231
Treatment. Much may be done in the way of prevention by
attending to the diet, clothing, pure air, and daily exercise,
Todide of iron and cod liver oil internally. Suppuration may be
prevented by minute doses of calcium sulphite, and locally ung.
cadmii or oleate of mercury.
2. Infantile Syphilis. Is due to hereditary taint, either
on the father’s or mother’s side ; or to vaccination with impure
lymph,
It may affect :
(a) Mucous membranes, giving rise to catarrh, or mucous
patches and ulcers on the cheek, glottis or epiglottis.
(b) Solid organs, giving rise to fibroid growths or gummata
which may be found in the lungs, liver, spleen, or pancreas.
(c) Bones, especially the long bones, either affecting the peri-
osteum, or the ossifying line of the shaft leading to separation
of the epiphysis.
Symptoms. These depend upon the degree to which the
system is affected. If it occurs while the child is in utero it
may cause the death of the fcetus, and syphilis is a common
cause of abortion. If less active the child may be born living,
but it is thin and shrivelled, looking like a little old man ; its
body is often covered with pemphygus ; it has “ snuffles” and
a hoarse cry, and as the internal organs are usually diseased
the child sooner or later dies. When a child is born with
hereditary syphilis, but apparently healthy you first notice
“ snuffies,” then a discharge from the nose which often leads to
ulceration of the septum. Then a rash consisting of copper-
colored flat spots appears on the perineum, genitals, and anus,
extending over the body, and there are frequently ecthymatous
and tubercular spots ; the hair and eyelids often fall out, and
the nails become diseased, while the teeth are peculiar, being
232 PEDIATRICS.
screw-driver shaped. “The fontanelles are slow in closing ; the
long bones become thickened and the epiphyses loosened, while
dactylitis is common.
Treatment. When a child is born with syphilis you should
treat both parents specifically for some months. In the child
begin the treatment as early as possible with mercury, and it is
indispensable to use it bots internally and externally. Hydrarg.
cum creta two or three times a day, or if it disagrees hydrarg.
bichlor. * to 7s gr. three times a day. ~ Ung. hydrarg. should be
smeared on a flannel band and applied to the belly, wrapping
freshly every day. Mercurial baths, 4 drm. to 14 drm. hydrarg.
bichlor. to two gallons of water.
At the same time improve the general health, and counteract
the tendency to anemia by giving iron and cod liver oil.
V.—DISEASES OF THE LIVER.
1. Jaundice is a symptom and not a disease, being due to
various causes.
(a) Icterus neonatorum. Usually begins on the second day,
and lasts a week or ten days. The skin and eyes are yellow ;
the stools are clay-colored ; and the urine is dark. I+ may be
simple or malignant.
(a) Benign. Is often the result of some trifling derange-
ment, and may be caused by severe labor, premature birth, or
exposure to cold, damp, or bad air. In many cases it is due to
the sudden transference of the chief blood supply from the
umbilical to the portal vein, giving rise to engorgement of the
hepatic circulation, The liver can usually be felt enlarged, but
the jaundice is seldom of any consequence.
(8)
and n
(i)
conjo!
(ii)
(iii
infect
(6)
in the
Dic
deepe
child |
The |
charg
abdo
Tre
doses
to ma
ligate
tuber
existe
as ned
gland
Pa
its ed
staing
phuri
the
hile
ould
hild
it is
rarg.
rarg.
ld be
ping
rarg.
eract
ue to
day,
llow ;
ay be
ange-
th, or
lue to
n the
of the
1, but
PEDIATRICS. 233
(8) Grave. May be an indication of very serious disease,
and may be due to:
(i) Atresia of the bile ducts from malformation. If this is
conjoined with umbilical hemorrhage it is rapidly fatal.
(ii) Syphilitic inflammation.
(iii) Umbilical Phlebitis and Pyemia. This depends on
infection like puerperal fever.
(6) Icterus of Childhood. This is due to the same causes as
in the adult, duodenal catarrh being the most common.
Diagnosis is usually easy. When it persists and becomes
deeper you would suspect the malignant form, especially if a
child of the same parents has died from a similar condition.
The pyemic form is characterized by fever, dry tongue, dis-
charge of blood and pus, and swelling and.tenderness of the
abdomen.
Treatment. In the simple form castor oil, followed by small
doses of sodee bicarb., is all that is necessary. In the variety due
to malformation, if hemorrhage occur it may be necessary to
ligate in mass.
9, Amyloid Liver. Known as waxy or lardaceous dis-
ease.
Cause. There is usually some cachexia such as syphilis,
tubercle, or scrofula, and itis most commonly brought on by the
existence of chronic suppurations and purulent discharges such
as necrosis or empyema. The kidneys, spleen, and lymphatic
glands are usually affected at the same time.
Pathoiogy. The liver is uniformly enlarged, heavy, dense,
its edges thin, of a gray and glistening color on section and
stained reddish-brown by iodine, while the addition of sul-
phuric acid gives a violet and blue color.
234 PEDIATRICS.
Symptoms. There is no pain, but a feeling of weight and
distension of the belly. Palpation feels the liver enlarged,
smooth, and hard, with sharp and prominent edges ; the diges-
tion is disturbed ; the spleen enlarged ; the child is easily tired;
there is anemia; and hyaline casts and albumen are found in
the urine.
Prognosis. It is less serious in the child than in the adult,
provided the source of irritation and suppuration can be
removed.
Treatment. Remove the cause, and thus obviate the symp-
toms such as diarrhea, vomiting and anemia. Then give a
liberal diet, and potassic iodide, and ferric citrate internally,
3. Fatty Liver. Is due to excess of farinaceous food, or
to tubercular disease.
Pathology. The liver is enlarged, soft, and doughy, its edges
blunt and receding. When cut it is yellowish-red, and shows
fat under the microscope.
Symptoms. There is slight tenderness over the liver, but
never jaundice or acites.
Treatment. If due to excess of farinaceous food stop that,
but if it accompanies scrofula or tubercular disease you must
treat the primary trouble.
VI. ACUTH INFECTIOUS DISHASES.
1. Mumps. Usually occurs before the 5th year, and
seidom after 14. It rarely occurs twice ; is usually epidemic ;
is especially common in the spring ; is extremely infectious, the
virus being carried by the breath; and it has a period of
incubation of from one to three weeks.
Pat
ducts,
days,
Syn
accom
gland
lasts f
day it
Met
mamm
Tre
to the
belladc
should
2, :
and is
may p
and it
Sym
sneezes
headac
diarrh¢
chin,
spots,
seem
fades,
j especia
Co
pheum
Etia
dual é
record
r, and
demic ;
us, the
siod of
PEDIATRICS. 235
Pathology. It is an inflammation of the salivary glands and
ducts, never going on to suppuration, but resolves in a few
days.
Symptoms. There is fever which often runs up to 108°,
accompanied by headache and vomiting. Then the parotid
gland swells, becoming tense, elastic, tender, and aching. This
lasts fror. 3 to 6 days, and then subsides, so that by the 10th
day it is all away.
Metastasis is common; affecting the testicle in boys, the
mamme in girls, A common sequence is deafness.
Treatment. Allay fever, and apply hot flannel or poultices
to the cheek, but avoid rubbing for fear of metastasis. Ung.
belladonnee with glycerine is often beneficial, and the bowels
should be regulated.
2. Measles. Is the most common of the eruptive fevers,
and is rarely fatal of itself, although some of its complications
may prove serious. The contagion is conveyed by the breath,
and it has a period of inc .bation of 10 days.
Symptoms. It begins with signs of catarrh; the child
sneezes, coughs, and its eyes are red and watery; there is
headache; fever; furred tongue; and often vomiting and
diarrhea. Then on the 4th day the eruption appears on the
chin, temples, and forehead, at first yellowish-red slightly raised
spots, which become of a deeper red. The fever and catarrh
seem to be increased as the rash appears. The eruption soon
fades, and it is often followed by a slight branny desquamation,
j especially when the rash has been profuse.
Complications. The most frequent and dangerous are broncho-
pneumonia and membranous croup.
Etiology. Asa rule it occurs only once in the same indivi-
dual but there are frequent exceptions, and cases have been
recorded where it has occurred twice in one month. It is
en
=
Se
Se
st
SS ae eee
eS
baa it a
236 PEDIATRICS.
especially contagious from the beginning till the end of the
eruptive stage when the infection becomes less and less active.
It is impossible to isolate a child in the same house with others
ruffering from the disease, and it takes three weeks from the
onset of the eruption before the sick child should be allowed to
mix with healthy children.
Treatment. The sick room should be kept at a temperature
of 65° F.; the diet should be milk and lime water, or barley
water, with any farinaceous food ; a mixture of tinct. aconite,
and tinct. camph. co. may be given for the cough and fever, and
if the latter is high quinine or antipyrine may be given; and
complications should be watched for and anticipated,
3. Rotheln. German measles or roseola is an exanthem
which resembles measles and scarlet fever combined, but is
commonly looked upon as a distinct species since an attack does
not protect against measles,
Symptoms. After a period of incubation of two weeks, there
is headache, fever, and often backache, and after twenty-four
hours an eruption of dusky-red, slightly elevated papuies,
appears on the cheeks, and quickly spreads to the body and
limbs. The catarrhal symptoms are seldom well marked but
the throat is sore, inflamed, and swollen.
Treatment: Similar to that of measles,
4. Scarlet Fever. Is a common infectious disease in
children, rarely occurring twice in the same person, but some-
times appearing in an abortive form in one who is already pro-
tected by a previous attack. It is most highly contagious at
the time of desquamation.
Symptoms. The period of incubation is from a few hours
to a few days, never more than a week. Then there is usually
a chil
red at
“ stra
rises,
on the
face a
Or
in, oft
variet
malig)
shown
being
it may
Seq’
early i
is apt
Tre
take e
bers o
disinf¢
mode
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PEDIATRICS, 237
a chill, vomiting, or a convulsion ; the tongue is furred, and
red at the edges, but soon becomes very red and rough,—the
“strawberry tongue ;” the throat is sore; the temperature
rises, and often soon reaches 105° ; the pulsé is very rapid ; and
on the 2nd day a scarlet pointed rash over a uniform pink sur-
face appears on the chest and neck, and body.
On the 5th day the rash fades, and desquamation sets
in, often fine branny scales or the skin may peel off. Three
varieties of scarletina are described: simplex, anginosa, and
maligna. In the malignant form the severity of the disease is
shown by the violence of the nervous phenomena, the child
being overpowered by the disease in some cases in 36 hours ; or
it may be owing to the severity of the throat affection.
Sequele. Diphtheria and rheumatism are apt to complicate
early in the disease, while later on albuminuria due to nephritis
is apt to occur ; and otorrhcea is common.
Treatment. The first thing to do in a case of scarletina is to
take every precaution to prevent its spread to the other mem-
bers of the family, and this can be done by early isolation and
disinfection. The child should be put in a well-ventilated,
moderately warm room; all carpets, curtains, and woollen
materials should be removed. The symptoms should be com-
bated as they occur.
Nephritis, indicated by albuminuria, dropsy, and anzmia
should be treated by pulv. jalap. co. and pilocarpine. The
diet throughout scarletina should be light, and free fror. albu-
men and meat.
6. Varicella,—Chickenpox has a period of incubation of
one week, and then slight fever, and an eruption appears, after
24 hours, of papules, which soon become vesicles, and pustules,
238 PEDIATRICS.
forming upon the back first and extending over the body and
limbs.
Treatment. Most cases only reqvire isolation and protection
from cold, regulation of the bowels, and the prevention of irri-
tation from picking the eruption.
6. Whooping Cough.—Pertussis is an infectious disease
consisting of catarrh of the air passages combined with peculiar
nervous symptoms. It occurs in epidemics, is contagious by
breath and expectoration, and can be conveyed by the atmos-
phere or clothes ; a second attack is rare.
Symptoms. After a short period of incubation the disease
begins by catarrh of the air passages, and a troublesome cough
which is worse at night, and soon becomes spasmodic, consist-
ing of a series of short hacks rapidly fol’»wing one another so
as to prevent inspiration, the child’s face becoming livid, and at
last it takes a long deep inspiration accompanied by the charac-
teristic “ whoop ” which gives the disease its name. This soon
begins again until the ch’ld brings up a large quantity of tough,
ropy mucus.
Complications. Convulsions and broncho-pneumonia are the
most important.
Treatment. At first any simple expectorant may be used,
and then when the spasm becomes established give belladonna
and pot. bromide, or zinc. sulphate and atropia. Quinine
also has a good effect, and locally the throat may be swabbed
with solution of silver nitrate, or resorcin.
VII.—DIsEaseEs OF THE SKIN.
In childhood the skin is very susceptible to disease ; it is
delicate and easily irritated by irregularities in diet, or dis-
ordered secretion ; by neglect and want of cleanliness; the
i?
+
tion «
circul
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Juinine
wabbed
PEDIATRICS. 239
frequency of gastro-intestinal disorders are apt to be accom-
panied by eruptions of the skin ; and the parasitic diseases are
common. The division of skin diseases which considers them
according to the local lesion seems the simplest.
1. Erythemata. (a) Lrythema is a superficial inflamma-
tion of the skin, occurring in slightly raised patches, diffused or
circumscribed ; the redness disappears on pressure but instantly
re.urns ; and it usually en 3 in slight furfuraceous disquama-
tion; the general symptoms being slight. You may have
Fugax when of a fleeting character; intertrigo when produced by
friction between folds of skin and want of cleanliness ; Pernio,
an unbroken chilblain ; Lave, occurs on anasarcous limbs due
to renal or cardiac disease ; Vodoswm, when confined to the
fore part of the leg in the form of large, oval, somewhat reised
patches resembling nodes.
_ Treatment. Remove all irritants; attend to cleanliness ;
apply soothing agents such as ung. zinci; lin. aq. calcis; or
fine starch; attend to the diathesis ; give an aperient, and
tonics may be indicated.
(6) Roseola consists of transient red patches or slightly
raised rose-colored spots, and is apt to be mistaken for measles.
(c) Urticaria is a febrile and non-contagious disease in
which hyperemic elevations similar to those that follow the
sting of a nettle are produced upon the skin, and consist of
wheals accompanied by tingling and burning, suddenly coming
and then going without leaving any stain, and unaccompanied
by desquamation. It is often produced by the ingestion of shell
fish.
Treatment. Remove any irritation such as flannels, avoid
draughts, use emollient and alkaline baths, and anoint the body
with vaseline ; relieve the work of the skin by aperients and
EM OR REP SEER RTET SS
4
sittaeatnit,
240 PEDIATRICS.
diuretics ; prevent the circulation of effete products such as
urea, or uric acid; tone up and lull by anodynes the nerve
paresis.
2. Vesicules. (a) Herpes consists of clusters of vesicles
situated on irregular-shaped inflamed patches.
There 18 circinatus occurring in a crescentic form and apt to
be mistaken for “ ringworm.”
Zoster or shingles because the groups of vesicles tend to
encircle one half of the body like a girdle ; it follows the course
of the cutaneous nerves ; is more frequent on the right than on
the left side ; lasts from 14 to 20 days ; occurs only once ; and
is accompanied by severe neuralgic pain. Preputialis and
labialis are other varieties.
Treatment. Allay irritation, apply ung. zinci, and give iron
and quinine tonics.
(b) Hczema is an acute inflammatory disease characterized by a
vesicular eruption closely packed upon a more or less inflamed
base, which quickly runs together, bursts, and is replaced by a
slightly excoriated surface that pours out a serous fluid, which
dries into crusts of a light yellow color. The discharge
stiffens linen. The principal varieties are semplex, rubrum and
impitiginodes.
Treatment. A typical case of eczema in its progress towards
cure passes through certain stages, viz.: erythema, vesication,
ichoration, pustulation and scabbing. It is a curable disease.
and its passage through these definite stages should be promoted.
It is aggravated by anything which irritates the skin from
within or without ; occasionally relieved or even aborted in its
slighter forms or earlier stages by soothing remedies ; liable to
be complicated by accidental occurrences consequent upon the
persistence of congestion, such as cedema, induration, atrophy,
ete. ;
and
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thick
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PEDIATRICS, 24]
etc. ; modified by constitutional conditions, such as gout, struma
and syphilis; influenced by organic diseases of the liver,
kidneys, heart or stomach ; and always associated with a lower-
ing of the general vitality of the system. sk yourself the
questions: What variety is it? What stage. ‘in? And are
there any complications? Lotions are best suited to the acute
and discharging, while ointments are best for the scaly, stages,
When the discharging stage lessens, and that of desquamation
approaches the «. ease may be regarded as chronic. When the
scaliness is distinct but no crusting, use astringents and avsorb-
ents ; when scaliness is well marked anda tendency to crusting
tarry compounds are best ; and when there is considerable
thickening and infiltration of plastic matter use oil of cade and
soft soap. In the acute form alkalies and arsenic are good ;
and in the chronic variety iron and arsenic are better.
3. Bulle. (a) Pemphigus is characterized by the appear-
ance of large round or oval blebs about one inch in diameter,
distended with a fluid which is at first clear, but soon becomes
milky, and often bloody; the bulle generally occur in sue-
cessive crops.
Treatment. It should be treated as an asthenic disease ; begin
with an aperient and then tonics with iron and mineral acids,
and good food.
(b). Rupia begins like pemphigus, but the blebs speedily fill
with a mixture of blood and pus, giving place to thick scales,
beneath which is more or less unhealthy ulceration, yielding a
nasty, dirty, fetid discharge augmenting the crusts with
successive layers of dried secretion, until they assume a conical
form. Rupia is pemphigus occurring in a syphilitic subject,
and is to be treated accordingly.
4. Pustule. (a). Hcethyma is characterized by solitary
pustules on an inflamed base and most frequently affects the
17
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242 PEDIATRICS.
shoulders, buttocks and limbs. It is caused by all that tends
to debility and impoverishment of the blood.
Treatment. Remove the exciting cause, and combat the
cachexia, giving tonics and proper food,
(b). Impetigo is characterized by an eruption of small flattened
pustules, usually arranged in clusters, and having a tendency to
run together and form thick and moist yellowish incrustations.
It usually begins on the face and head.
Treatment. The natural course of the disease is short and
definite. As the discharge is contagious, cleanliness is import-
ant ; so destroy the activity of the pus, and change the character
of the surface that secretes it. Remove the scabs by poulticing,
and apply ung. hydrag. ammon. chlor. (gr. v. to oz. i.), and
give tonics.
5. Papules. (a). Lichen is characterized by minute hard, -
dry elevations of the skin, accompanied by tingling and itching,
and slight desquamation. The varities are simplex, planus, and
urticatus or “ red gum.”
(6). Prurigo is a chronic inflammation of the skin accom-
panied by the development of papules, general thickening of the
skin and intense itching.
Treatment. Allay itching and give good diet and tonics.
6. Squame. (a). Psoriasisis characterized by the develop.
ment of dry closely packed shining scales seated on a hyperemic
cutis. The elbows and knees are the most common sites ; it is
chronic ; relapses are frequent ; and it is often hereditary.
Treatment.. Locally ung. ac. crysophanic, and internally
arsenic is a specific.
(0). Pityriasis isa superficial and chronic inflammation of the
skin, attended with redness and itching, and the production of
minute white scales like bran. ‘ Dandruff” is a raild form.
nds
PEDIATRICS, 243
Treatment. Locally a wash of hydrarg. bichlor, and arsenic
internally.
(c). Ichthyosis is characterized by thick, hard, dry, and imbri-
cated scales of a dirty gray color, resting upon an inflamed
surface. It is often congenital and hereditary.
Treatment. Can only be relieved by emollient applications,
and tonics with arsenic,
7. Tubercule. (a). Elephantiasis.
(6). Molluscum.
(c). Acne is characterized by small isolated pustules with deep
red bases, which after suppurating and bursting, leave behind
them minute hard, red tumors, the seat of which is the
sebaceous follicles.
(d). Keloid. Is like a cicatrix of a burn.
8. Parasitici. (a). Tinea Tonsurans is recognized by the
thickened and brittle or broken condition of the affected hairs
by the brawny eruption, and the roundness of the diseased
patches. When not on the scalp it is called tinea circimmata,
and popularly known as “ ring-worm.”
(b). Tinea Favosa is known by the small cup-shaped yellow
crusts, each containing a hair in its centre, and somewhat
resembling a honey-comb ; there is itching ; the hairs are brittle
- and fall out; and it has an offensive odour.
(c). Tinea Decalvans, or alopecia areata, is where the hair falls
out in one or more circular or oval spots, leaving perfectly
smooth bald patches, which may be small in size or extend over-
the entire scalp.
(d). Tinea Sycosis is known by spots of erythematous
inflammation which involve the hair follicles causing successive
eruptions of small accuminated pustules. It is properly known
as the barber’s itch.
PEDIATRICS.
Treatment. Tinea is best cured by the thorough application
of some parasiticide, such as tinct. of iodine, crysophanic acid
in ether, etc.
(e) Tinea Versicolor usually appears in the front of the chest
or abdomen in the form of small patches of a dull reddish color,
which gradually increase in size, and assume a yellowish tint.
Treatment. Solution of hydrarg. bichlor., or sulphurous
acid ; or hyposulphite of soda.
(f) Scabies commences as a papular, vesicular, or even
pustular eruption, which ruptures and produces excoriations ; is
intensely itchy ;-is most frequent in the flexures of the
joints, especially the fingers, toes, elbows and thighs ; and the
itching is mostly at night when the child is warm in bed. | The
history and the microscope confirm the diagnosis. It is due to
an animal parasite.
Treatment, The parts should be well washed with soap and
water and an ointment of sulphur vivum rubbed in thoroughly,
which is a specific.
THE COPP, CLARK COMPANY, LIMITED, PRINTERS, TORONTO.
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GENERAL INDEX.
Abdominal pregnancy - :
Abortion, Nature and Seudaitioni of,
Artificial, - -
Abnormal position of foetus
Adherent placenta’ - - -
Amyloid liver : . - -
Accidental hemorrhage - - -
Anesthetics in labor - : - - :
Amenorrhea - - - -
Anteversion and anteflexion - -
Anterior polio-myelitis -
Atresia of vagina - : - . - - -
Breech presentation -. - : :
Breast, Diseases of - : - :
Bimanual examination : - - -
Bladder, Diseases of - - - -
Bronchitis : : - en
Caruncule myrtiformes - - emits : :
Cancer of uterus :
Caruncle : - : - - -
Cesarean Section : - : : : -
Calculi of bladder - - : - - : :
Cervix, Laceratiou of - - Mh a ee BD
Childbed, Diseases of - - - : : “
Chickenpox : - - ° ° * :
Clitoris - : eis . : -
Corpus luteum - - pide SNe 7
Conjugate-diameter of pelvis- + - - °
Cord, Presenting hee
Complications of labor - hee ee. erste
Convulsions, Puerperal - - - -
Infantile ~ - - - . :
PAGE
233
Se eg ie SM ten efecto agglign Pace tag wR A
246 INDEX.
Se Rae SIN A DIR LM ON CN ig 208 Face
Convalescence, Disordersof - - - + + + «© * 107 Fatty
Colpitis - - : - - - : . : . - 142 Fecu:
Qramictomy «© 6 88 ee ee ee Fistu
Crede’s method in 3rd stage - “ : . ° . . 63 Fissu
Curette - - - ° : : ° . ° ° : - 136 Fibre
Cystitis - - - : - - - : ° : ° 184 Fibre
Developmentofovum - - - - - * + + + 1 Feta
Decidua vera, reflexa and serotina’ - . . - . - 16 Flatu
Descent of head - - - - : - ° ° ° - 56 Flexi
Deventer’s method in after-coming heat - - : - - 70 Fossa
Deformities - . . . . ° . . : ‘ «\ Font:
Dentition - ‘ ° : ° ° . ‘ R % i 201 Force
Diameters of pelvis - : : . . ° i “ - 562
of foetal head - - . - . . . “ 54 Funis
Diagnosis of female diseases - - - - - : . - 128 Galac
Digital examination - : . . . . ° ’ 132 Gast
Be i eee eine Ue ae alot ee aR Gern
Disorders of menstruation - - : : - . . - 143 Graat
Displacements of uterus - - - : - . - - 157 | Gyna
cA aaa oe ee a an COMA aL na 206 Hanc
Diphtheria - : - : ° : . . " : - 223 | = Hem
Diathetic diseases - - - * * * © + 92 229
Dystocia Behe ke eee Ups Do Lanoeic tale Sate ne Sie) Sane
Dysmenorrheea - : : ° . ° . ® * 145, 160 Hem
Dysentery - : - ee ° . ° . ° - 208 Head
i ee ee ee 186 Hym
Eclampsia - : . . - . : . ‘ - 90
Ectopic gestation - - - we che ume or treme] Biase wire § 38 Hydr
Embryo, Development of = - . : - . : : - 19 Hyd
Embryotomy - Ce ates . Sea eee on a 104 | Hyd
Emmet’s button-hole operation - — - A eta cas ae. - 187 Hyst
PROVING ee eee ee Bs eee 228 Hyst
Eutocia - - : - - a. : : erage - 54 Hour
Endometritis - . : - . ;. . . i . 153 Icter
Ergot, Uses and contraindications of - - - - - 665, 66 f = Incli
Expellent forces of labor - : - : - - - - 45 Impe
Extension of head : whines : - : - - wis EP | Infar
Fallopian tubes, Structure of - - -° * °° ° ° 5 Indu:
Tbedliedh ew ae eee Inve.
INDEX. 247
208 Face presentation - . ‘ . ‘ A , A P 66
107 Fatty liver - : , shh : : J . . 234
142 Fecundation - . : fs ‘ . : : ? ; 11
103 Fistulee - - - - ° - ‘ . ‘< . 7 - 142
63 Fissure of the urethra ° ° . . . “ : P 187
136 Fibro-myoma - - - - r * FS é : s - 167 l
184 Fibro-cystic ° - - - « > ‘ é : bs 169
12 Foetal head - - : - - - ‘ ; ; ‘ 53 I
16 Flatus vaginalis ° « “ ; ; : : : ; 140 Hy
56 Flexion of head - - ° : * ‘ . ; - «56
70 Fossa navicularis . é ‘. * ; p ‘ : x 2
72 (ES ee re i ee er em ry
201 Forceps, Uses of - - - - - - - - 99, 100
52 in Breech cases-§ - - - °° ° PET ap
54 Fuuis, Prolapseof - - - - + * * 5 8 81
128 ETE ie re ie re ee aan he
199 «| Gastrincaterrh - = 208
136 German measles - - - . . ; é R . - 236
143 Graaffian follicles - . . : . ‘ ‘ ; i 6
157 Be eee 127
206 Hand-feeding of infants - - - - - * °° 196
223 | Hemorrhage, Accidental eh HG, Preiss . - « 86
229 Post partum - a ea ae giecrihe 87
64 Secondary uterine - -~— - ; ‘ a gaa ae
, 160 Hematocele - - ° De nae ide on melt Rose N Ret 177
208 Head, Large, the cause of dystocia ° . is 2 5 <a
186 Hymen, Structure of Bees Somers se He, Seles 2
90 Imperforate - - - - . . ‘ - oe 144
38 Hydramnion - - - : - . ‘ , : ° 31
19. Hydatidiform mole . - . . , é ‘ ‘ - 382
104 Hydrocephalus - ° ° . . * ‘ s ; as 212
187 Me at oe
228 PCY 8 190
54 Hour-glass contraction - - . - . ‘ : “ » 82
153 Icterus neonatorum - ° - “ . a . ‘s ° 232
5, 66 Inclined planes of pelvis - - - - . - - 68
45 } Impededuterineefforts - - - - -°- * °° 64
57 | Infantile spinal paralysis ee ee a Es ge) ee
5 | Induration of os Ret eWeek ae ea . 90
179 Inversion of the uterus - - ee: - 165, 94
248 INDEX.
Induction of premature labor
Insanity, Puerperal . :
Inertia - : : .
Intestinal tract, Diseases of -
Intestinal obstruction, and intussusception
Inspection of external genitals -
Irrit vbility of the bladder :
Jaundice of children - :
Labia majora and minora -
Laparo-elytrotomy -
Laceration of cervix -
Laryngismus stridulus. -
Labor, Cause of onset -
Symptoms - ; . : :
Stages of : .
Duration of : : -
Management~ - - . -
Leucorrheea - . -
Pe Liquoramnii- + + - «+ -
Martin’s treatment of after-coming head
Malformations, of vulva
of vagina -~— - x
of uterus - ° ; ,
Marasmus : : .
Menstruation - : . “ ‘
Merobranes, Formation of -
Cause of dystocia - :
Metritis, acute and chronic - -
Miscarriage - - - . . y
Munde’s pill - : - ‘ a sintioa
Mumps - - er iuyrie . area
New growths, of vulva
Mechanism of ° 2 ‘
Liver, Diseases of, inchildren - - :
Mastitis - ° ° F . 5 i
Menorrhagia ss - : - - . ‘
Measles” - - : - - : ‘
Mons veneris” - - - - Peatnrh
Multiple pregnancy : Sura abut
Nervous mechanism of labor’ - : -
New
Neu
Ner
New
Nip]
Nuc
Obli
Ope!
O6p!
Oval
Ova:
Ova:
Oval
Ovu:
— Ovu
Parc
INDEX,
of vagina
Neuroses - - :
Neurasthenia - .
Nervous system of children
New born infarts, Treatment of
Nipples, Sore
Nucleus of vitellus
Obliquity of uterus
Operations, Obstetric
Odphoritis - -
Ovaries, Structure of
Diseases of
Ovarian tumors
Ovariotomy - -
Ovaro-hysterectomy -
Ovum =. - -
_ Ovulation -
Parovarium -
Parametritis -
Pelvis, Description of
Contraction -
Perineum, Rupture of
Perimetritis - -
Pediatrics -
Peptonizing milk
Pertussis : - - .
Persistent, 3rd position -
Positions of vertex -
Pelvimetry - - -
Perineum, Management of
Post partum hemorrhage -
Polypi_ - - : :
Placenta, Formation of
Retention of -
Previa :
Planes of pelvis -
Pleurisy - :
Phlegmasia dolens
Physical signs of chest -
Pneumonia - :
Signs of .
Disorders of -
Hygiene of
Abnormal
Duration of
Extrauterine
Premature labor -
Induction of
Prolapsus, Uteri - -
of urethral mucous cenivans
Porro’s operation TUE AE,
Presentation and position - ~-
Prague method in breech cases -
Pseudo-hypertrophic ——
Pudenda -~ - a
Puerperal fever - ~~ -
Puerperal venous thrombosis mer einbdlinia
Pulmonary obstruction - > -
Puerperal insanity - -
Quickening -
Restitution -
Retroversion - - - - + °
Retroflexion - ~° -
Respiratory system in ohtitesn, Abasaie of
Rigidity of os 0g Mens KEEN, ee,
Rotation of head - - - - -
Round ligaments Uva ke
Rétheln - = -
Rupture of uterus -
Salpingitis- -
Scarlet fever -
Scrofula - - ~-
Skin, Diseases of -
Second position vertex
Segmentation of vitellus -
Size and form causing dystocia
Shoulder presentation - ~-
Speculum, vaginal -~ -
Sterility - -
Stenos
Sprue
Stoma
Sound
Sutur
Subin
Synco
Syphi
Tenac
Thom
Thrus
Trunk
Tubes
Tubal
Tumo
Tube
Turni
Twin:
Umbi
INDEX. 251
22 Stenosis ofosuteri - - + «+ «+ -« . «6.4 152
24 Sprue - e - . ° . ° = ©> - « 202
29 Stomatitie- -— + © © © w 8 © © «6 203
30 Sound, uterine -~ - go ee ee al et ee) St
30 Sutures of foetal head By Gl ate Ge ee teal 54
m MOMs © 6 ee le
38 eS a a a 93 |
37 Syphilis, Infantile. .- + + + + © + « © 991
97 Tenaculum BEM ig gt”. Sg eee Cierg eo a 135
163 Thomas’ operation- - - + + + «© = + + 107
187 ES a Ce, ee 202
106 Trunk, Expulsion of : . - : . ° ; 6 e 87
55 Tubes, Diseases of _ - - . ; . ° . ° F 179
70 Tubal pregnancy - - - + + + + + «+ «+ 38 i
215 Tumors of vagina = - - ie wie a es 80
1 Tubercular meningitis - . ‘ ‘ ; ri ‘ - 213 |
119 Turning - . : . R ° . ‘ ; ‘ * 101 j
120 Twins, Management of - - . : go ed . ° 73, 74 ¢
121 Umbilical vesicle - - : . . . . ° . 15
124 cord : - . . : . ° ° ° - 18
5 ' Urethra, Diseases of - t - - - : : : : 186.
57 Uterus, Structure of - . . : . . ° ° ° 3
0) Diseasesof - - + + © + © © » 143
162 a SO Se
ae Vagina, Structure of Tt Sa A ee i SM Soa eT 2
79 Diseases of : ° ie 8 . oo hS on, wag ae
75 Vaginismus . . ° ° . ° . . ° ‘ 141
3 Version - - . . ° ¢ ‘ . . ‘ , - 101
236 Vertex, Positions of - : . . . : - - - 55, 58 :
5, 96 Vesico-vaginal fistula - - - + + + +: «+ «+ 142
ie OS i ea a ar ee {
236 Viability Vet OS Sh a a ae oe Ue ae eet |
229 Vulva, Diseases of - . . : . . - : 97 1
238 BN o a. res. bY go ee ye ee eel
57 Wet-nurse, Selection of - . . . : - - - 199 :
13 Whooping cough - WPA | ipod ge % Log a. Paginas bree. Nee a _
72 Worms + - - - pieces 9 flee ol igt < SS Rey 290. i
71 |
133 . :
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